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psnet.ahrq.gov/issue/lethal-hidden-curriculum-death-medical-student-opioid-use-disorder
October 19, 2022 - Commentary
A lethal hidden curriculum—death of a medical student from opioid use … A Lethal Hidden Curriculum - Death of a Medical Student from Opioid Use Disorder. … A Lethal Hidden Curriculum - Death of a Medical Student from Opioid Use Disorder.
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psnet.ahrq.gov/issue/hastened-death-due-disease-burden-and-distress-has-not-received-timely-quality-palliative
October 31, 2023 - Commentary
Hastened death due to disease burden and distress that has not received … Hastened death due to disease burden and distress that has not received timely, quality palliative care … Hastened death due to disease burden and distress that has not received timely, quality palliative care
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psnet.ahrq.gov/issue/its-difference-between-life-and-death-views-professional-medical-interpreters-their-role
August 10, 2010 - Study
"It's the difference between life and death": the views of professional medical … "It's the difference between life and death": The views of professional medical interpreters on their … "It's the difference between life and death": The views of professional medical interpreters on their … controlled trial assessing the efficacy of an electronic discharge communication tool for preventing death
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psnet.ahrq.gov/node/39322/psn-pdf
February 24, 2010 - Complications and death at the start of the new academic
year: is there a July phenomenon? … Complications and death at the start of the new academic year: is
there a July phenomenon? … https://psnet.ahrq.gov/issue/complications-and-death-start-new-academic-year-there-july-phenomenon
Trauma … https://psnet.ahrq.gov/issue/complications-and-death-start-new-academic-year-there-july-phenomenon
https
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psnet.ahrq.gov/issue/preventable-deaths-due-problems-care-english-acute-hospitals-retrospective-case-record-review
July 20, 2022 - As in prior studies , reviewers' agreement on whether a death was preventable was only moderate. … December 16, 2020
Problems in care and avoidability of death after discharge from intensive
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psnet.ahrq.gov/issue/next-kin-involvement-regulatory-investigations-adverse-events-caused-patient-death-process
March 02, 2022 - Next of kin involvement in regulatory investigations of adverse events that caused patient death … Text:
Next of kin involvement in regulatory investigations of adverse events that caused patient death … Text:
Next of kin involvement in regulatory investigations of adverse events that caused patient death
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psnet.ahrq.gov/issue/association-between-primary-care-physician-diagnostic-knowledge-and-death-hospitalisation-and
May 27, 2020 - Study
Association between primary care physician diagnostic knowledge and death, … Association between primary care physician diagnostic knowledge and death, hospitalisation and emergency … Association between primary care physician diagnostic knowledge and death, hospitalisation and emergency
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psnet.ahrq.gov/issue/hospital-accident-lessons-learned-death-conviction-and-healing
March 06, 2005 - Audiovisual Presentation
A Hospital Accident: Lessons Learned – A Death, A Conviction … Citation Text:
A Hospital Accident: Lessons Learned – A Death, A Conviction, and A Healing. … Cite
Citation
Citation Text:
A Hospital Accident: Lessons Learned – A Death
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psnet.ahrq.gov/issue/patterns-unexpected-hospital-deaths-root-cause-analysis
March 13, 2019 - quite arbitrary , and new methods and technologies are needed to identify actual patterns of evolving death
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.60_slideshow.ppt
May 01, 2004 - In-hospital death
Death in ICU (>5 days) Death in ICU (>5 days)
Conventional Treatment (%)
Intensive … 14 days ICU 15.7% 11.4%
> 14 days ventilator 11.9% 7.5%
Septicemia in ICU 7.8% 4.2%
In-hospital death … 10.9% 7.2%
Death in ICU (>5 days) 20.2% 10.6%
Sheet2
Sheet3
Chart2 (2)
> 14 days ICU > 14 … (all patients) In-hospital death (all patients)
Death in ICU (>5 days) Death in ICU (>5 days)
Conventional … Death in ICU
(>5 days)
Conventional Treatment (%)
Intensive Treatment (%)
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psnet.ahrq.gov/web-mm/when-vomit-gets-way-aspiration-resulting-death-during-endoscopy
March 18, 2020 - When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy
Citation Text: … When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet [internet]. … When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet [internet]. … event, which most likely led to asphyxiation and severe hypoxia resulting in cardiopulmonary arrest and death … When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy. PSNet [internet].
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psnet.ahrq.gov/issue/causes-their-death-appear-unto-our-shame-perpetual-why-root-cause-analysis-not-best-model
September 27, 2016 - Study
The causes of their death appear (unto our shame perpetual): why root cause … The Causes of Their Death Appear (Unto Our Shame Perpetual): Why Root Cause Analysis Is Not the Best … The Causes of Their Death Appear (Unto Our Shame Perpetual): Why Root Cause Analysis Is Not the Best … March 3, 2019
Death by suicide within 1 week of hospital discharge: a retrospective study
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psnet.ahrq.gov/node/36606/psn-pdf
January 31, 2007 - Cause of death: sloppy doctors.
January 31, 2007
Caplan J. Time. January 15, 2007. … https://psnet.ahrq.gov/issue/cause-death-sloppy-doctors
This article reports on an industry-supported … https://psnet.ahrq.gov/issue/cause-death-sloppy-doctors
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psnet.ahrq.gov/sites/default/files/2024-08/spotlight_case_a_fatal_twist_in_pseudohyperkalemia_slides.pptx
January 01, 2024 - misinterpretation of lab results led to the missed diagnosis of pseudohyperkalemia, incorrect treatment and death … Autopsy confirmed sudden cardiac arrest without myocardial infarction as the cause of death.
7
7 … Unfortunately, the patient deteriorated and suffered sudden cardiac death likely due to TdP (meaning … /HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac … death: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical
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psnet.ahrq.gov/issue/case-birth-and-death-high-reliability-healthcare-organisation
June 18, 2013 - Commentary
A case of the birth and death of a high reliability healthcare organisation … A case of the birth and death of a high reliability healthcare organisation. … A case of the birth and death of a high reliability healthcare organisation.
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psnet.ahrq.gov/perspective/measuring-and-responding-deaths-medical-errors
April 01, 2008 - the IOM report, multiple researchers and commentators have produced widely varying estimates of the death … If true, this would make medical error the third leading cause of death in the US. … The 2016 study—and earlier studies that also put the death toll from medical errors in the hundreds of … An electronic death review process that relied on input from frontline clinicians has been shown to … Identifying preventable harm through death reviews should be viewed as part of an overall strategy to
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psnet.ahrq.gov/web-mm/fatal-twist-pseudohyperkalemia
February 10, 2021 - Autopsy confirmed sudden cardiac arrest without myocardial infarction as the cause of death. … Unfortunately, the patient deteriorated and suffered sudden cardiac death likely due to TdP (meaning … /HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac … death: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical … WebM&M Cases
Delay in Appropriate Diagnosis and Treatment Leading to Death
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psnet.ahrq.gov/issue/outreach-and-early-warning-systems-ews-prevention-intensive-care-admission-and-death
September 20, 2011 - Outreach and Early Warning Systems (EWS) for the prevention of Intensive Care admission and death … Outreach and Early Warning Systems (EWS) for the prevention of Intensive Care admission and death of … Outreach and Early Warning Systems (EWS) for the prevention of Intensive Care admission and death of … Settings Help Improve Management of Sepsis
May 31, 2023
Eliminating preventable death
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psnet.ahrq.gov/issue/liability-associated-obstetric-anesthesia-closed-claims-analysis
July 13, 2010 - Investigators found that while the proportion of maternal death and newborn death or brain damage claims … September 1, 2021
Frequency and type of situational awareness errors contributing to death
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psnet.ahrq.gov/node/41988/psn-pdf
January 23, 2013 - What a new doctor learned about medical mistakes from
her Mom's death.
January 23, 2013
Allen M. …
https://psnet.ahrq.gov/issue/what-new-doctor-learned-about-medical-mistakes-her-moms-death
This … https://psnet.ahrq.gov/issue/what-new-doctor-learned-about-medical-mistakes-her-moms-death