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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/33956/psn-pdf
    March 07, 2005 - The Report of the Manitoba Pediatric Cardiac Surgery Inquest: An Inquiry into Twelve Deaths at the Winnipeg Health Sciences Center in 1994. March 7, 2005 Inquest, Manitoba Pediatric Cardiac Surgery. Winnepeg, Manitoba: Provincial Court of Manitoba; 1999. ISBN 0771115164. https://psnet.ahrq.gov/issue/report-manito…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/40727/psn-pdf
    October 21, 2011 - Saving lives by studying deaths: using standardized mortality reviews to improve inpatient safety. October 21, 2011 Lau H, Litman KC. Saving lives by studying deaths: using standardized mortality reviews to improve inpatient safety. Jt Comm J Qual Patient Saf. 2011;37(9):400-408. https://psnet.ahrq.gov/issue/savin…
  3. psnet.ahrq.gov/issue/report-faults-childrens-hospital-medication-errors
    August 24, 2016 - November 21, 2007 MGH death spurs review of patient monitors. … June 8, 2011 'Alarm fatigue’ a factor in 2nd death.
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/853247/psn-pdf
    September 06, 2023 - Dangers and deaths around black pregnancies seen as a ‘completely preventable’ health crisis. September 6, 2023 West S. KFF Health News. August 24, 2023. https://psnet.ahrq.gov/issue/dangers-and-deaths-around-black-pregnancies-seen-completely-preventable- health-crisis The challenge of unsafe maternal care is gai…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45039/psn-pdf
    September 27, 2016 - Deaths following prehospital safety incidents: an analysis of a national database. September 27, 2016 Yardley I, Donaldson LJ. Deaths following prehospital safety incidents: an analysis of a national database. Emerg Med J. 2016;33(10):716-721. doi:10.1136/emermed-2015-204724. https://psnet.ahrq.gov/issue/deaths-fo…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35468/psn-pdf
    April 12, 2011 - Medical record review of deaths, unexpected intensive care unit admissions and clinician referrals: detection of adverse events and insight into the system. April 12, 2011 Dunn KL, Reddy P, Moulden A, et al. Medical record review of deaths, unexpected intensive care unit admissions, and clinician referrals: detect…
  7. psnet.ahrq.gov/issue/rate-preventable-mortality-hospitalized-patients-systematic-review-and-meta-analysis
    July 27, 2022 - Review Rate of preventable mortality in hospitalized patients: a systematic review and meta-analysis. Citation Text: Rodwin BA, Bilan VP, Merchant NB, et al. Rate of preventable mortality in hospitalized patients: a systematic review and meta-analysis. J Gen Intern Med. 2020;35(7):2099-2…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47211/psn-pdf
    November 16, 2018 - A conceptual framework to reduce inpatient preventable deaths. November 16, 2018 Davis DP, Aguilar SA, Lawrence B, et al. A Conceptual Framework to Reduce Inpatient Preventable Deaths. Jt Comm J Qual Patient Saf. 2018;44(7):413-420. doi:10.1016/j.jcjq.2018.01.003. https://psnet.ahrq.gov/issue/conceptual-framework-…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45652/psn-pdf
    June 29, 2017 - Increases in drug and opioid overdose deaths—United States, 2000–2015. June 29, 2017 Rudd RA, Seth P, David F, et al. Increases in Drug and Opioid-Involved Overdose Deaths - United States, 2010-2015. MMWR Morb Mortal Wkly Rep. 2016;65(50-51):1445-1452. doi:10.15585/mmwr.mm655051e1. https://psnet.ahrq.gov/issue/inc…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47154/psn-pdf
    May 23, 2018 - Comparison of military and civilian methods for determining potentially preventable deaths: a systematic review. May 23, 2018 Janak JC, Sosnov JA, Bares JM, et al. Comparison of Military and Civilian Methods for Determining Potentially Preventable Deaths: A Systematic Review. JAMA Surg. 2018;153(4):367-375. doi:1…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46899/psn-pdf
    March 21, 2018 - Patient Deaths at Arbour Health Systems—Westwood Lodge Hospital and Pembroke Hospital. March 21, 2018 Disability Law Center. Boston, MA: February 2018. https://psnet.ahrq.gov/issue/patient-deaths-arbour-health-systems-westwood-lodge-hospital-and- pembroke-hospital Patients with mental health concerns are vulnerab…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43253/psn-pdf
    May 01, 2015 - Interim Report: Review of VHA's Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths at the Phoenix Health Care System. May 1, 2015 Washington, DC: VA Office of the Inspector General; May 28, 2014. Report No. 14-02603-178. https://psnet.ahrq.gov/issue/interim-report-review-vhas-patient-wait-times-s…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47333/psn-pdf
    October 10, 2018 - Changing dynamics of the drug overdose epidemic in the United States from 1979 through 2016. October 10, 2018 Jalal H, Buchanich JM, Roberts MS, et al. Changing dynamics of the drug overdose epidemic in the United States from 1979 through 2016. Science (1979). 2018;361(6408). doi:10.1126/science.aau1184. https://p…
  14. psnet.ahrq.gov/issue/factors-associated-unanticipated-day-surgery-deaths-department-veterans-affairs-hospitals
    July 12, 2010 - Study Factors associated with unanticipated day of surgery deaths in Department of Veterans Affairs hospitals. Citation Text: Bishop MJ, Souders JE, Peterson CM, et al. Factors associated with unanticipated day of surgery deaths in Department of Veterans Affairs hospitals. Anesth Analg…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/35365/psn-pdf
    February 17, 2011 - Accidental deaths, saved lives, and improved quality. February 17, 2011 Brennan TA, Gawande AA, Thomas EJ, et al. Accidental Deaths, Saved Lives, and Improved Quality. New England Journal of Medicine. 2005;353(13). doi:10.1056/nejmsb051157. https://psnet.ahrq.gov/issue/accidental-deaths-saved-lives-and-improved-qua…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/36298/psn-pdf
    September 27, 2006 - Hospital Reporting of Deaths Related to Restraint and Seclusion.  September 27, 2006 Levinson DR. Washington DC: Office of the Inspector General; September 2006. OEI-09-04-00350 https://psnet.ahrq.gov/issue/hospital-reporting-deaths-related-restraint-and-seclusion This report presents findings from an investigatio…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846764/psn-pdf
    March 29, 2023 - Senators threaten consequences after VA confirms 4 deaths tied to computer system tested in Spokane. March 29, 2023 Donovan-Smith O. Spokesman Review. March 15, 2023. https://psnet.ahrq.gov/issue/senators-threaten-consequences-after-va-confirms-4-deaths-tied-computer- system-tested-spokane Implementations of elec…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45862/psn-pdf
    February 08, 2017 - Learning, Candour and Accountability. A Review of the Way NHS Trusts Review and Investigate the Deaths of Patients in England. February 8, 2017 Newcastle Upon Tyne, UK: Care Quality Commission; December 2016. CQC-356-122016. https://psnet.ahrq.gov/issue/learning-candour-and-accountability-review-way-nhs-trusts-rev…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43444/psn-pdf
    August 27, 2014 - Patient-safety–related hospital deaths in England: thematic analysis of incidents reported to a national database, 2010–2012. August 27, 2014 Donaldson LJ, Panesar S, Darzi A. Patient-safety-related hospital deaths in England: thematic analysis of incidents reported to a national database, 2010-2012. PLoS Med. 201…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60536/psn-pdf
    May 27, 2020 - Nursing home workers warned government about safety violations before COVID-19 outbreaks and deaths. May 27, 2020 Ellis B, Hicken M. CNN. May 14, 2020. https://psnet.ahrq.gov/issue/nursing-home-workers-warned-government-about-safety-violations-covid-19- outbreaks-and-deaths Long-term care and skilled nursing faci…

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