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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…
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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…
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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.
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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…
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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…
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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…
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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…
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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-…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…