-
psnet.ahrq.gov/node/43602/psn-pdf
October 15, 2014 - Classifying errors in preventable and potentially
preventable trauma deaths: a 9-year review using the
Joint Commission's standardized methodology.
October 15, 2014
Vioque SM, Kim PK, McMaster J, et al. Classifying errors in preventable and potentially preventable trauma
deaths: a 9-year review using the Joint Com…
-
psnet.ahrq.gov/node/35023/psn-pdf
March 04, 2011 - Building a framework for trust: critical event analysis of
deaths in surgical care.
March 4, 2011
Thompson A, Stonebridge PA. Building a framework for trust: critical event analysis of deaths in surgical
care. BMJ. 2005;330(7500):1139-42.
https://psnet.ahrq.gov/issue/building-framework-trust-critical-event-analysi…
-
psnet.ahrq.gov/node/45301/psn-pdf
April 22, 2017 - Reviewing deaths in British and US hospitals: a study of
two scales for assessing preventability.
April 22, 2017
Manaseki-Holland S, Lilford RJ, Bishop JRB, et al. Reviewing deaths in British and US hospitals: a study of
two scales for assessing preventability. BMJ Qual Saf. 2017;26(5):408-416. doi:10.1136/bmjqs-20…
-
psnet.ahrq.gov/node/44466/psn-pdf
September 16, 2015 - Is researching adverse events in hospital deaths a good
way to describe patient safety in hospitals: a
retrospective patient record review study.
September 16, 2015
Baines RJ, Langelaan M, de Bruijne M, et al. Is researching adverse events in hospital deaths a good way
to describe patient safety in hospitals: a re…
-
psnet.ahrq.gov/node/43667/psn-pdf
November 12, 2014 - Learning from preventable deaths: exploring case record
reviewers' narratives using change analysis.
November 12, 2014
Hogan H, Healey F, Neale G, et al. Learning from preventable deaths: exploring case record reviewers'
narratives using change analysis. J R Soc Med. 2014;107(9):365-75. doi:10.1177/0141076814532394…
-
psnet.ahrq.gov/node/45898/psn-pdf
August 16, 2017 - Estimating hospital-related deaths due to medical error: a
perspective from patient advocates.
August 16, 2017
Kavanagh KT, Saman DM, Bartel R, et al. Estimating Hospital-Related Deaths Due to Medical Error: A
Perspective From Patient Advocates. J Patient Saf. 2017;13(1):1-5. doi:10.1097/PTS.0000000000000364.
http…
-
psnet.ahrq.gov/node/47054/psn-pdf
July 19, 2018 - A target to achieve zero preventable trauma deaths
through quality improvement.
July 19, 2018
Hashmi ZG, Haut ER, Efron DT, et al. A Target to Achieve Zero Preventable Trauma Deaths Through
Quality Improvement. JAMA Surg. 2018;153(7):686-689. doi:10.1001/jamasurg.2018.0159.
https://psnet.ahrq.gov/issue/target-achi…
-
psnet.ahrq.gov/node/50606/psn-pdf
October 30, 2019 - One doctor. 25 deaths. How could it have happened?
October 30, 2019
Healy J, Farr I, Feiger L, Duffy C. New York Times. October 11, 2019.
https://psnet.ahrq.gov/issue/one-doctor-25-deaths-how-could-it-have-happened
Systemic failures persistently undermine processes meant to keep patients safe. This news story discu…
-
psnet.ahrq.gov/node/851071/psn-pdf
June 28, 2023 - Inside the preventable deaths that happened within a
prominent transplant center.
June 28, 2023
Blau M. ProPublica. June 14, 2023.
https://psnet.ahrq.gov/issue/inside-preventable-deaths-happened-within-prominent-transplant-center
Medical errors during organ transplants can have catastrophic consequences. This repo…
-
psnet.ahrq.gov/node/36037/psn-pdf
June 25, 2009 - Preventable deaths in patients admitted from emergency
department.
June 25, 2009
Lu T-C, Tsai C-L, Lee C-C, et al. Preventable deaths in patients admitted from emergency department.
Emerg Med J. 2006;23(6):452-5.
https://psnet.ahrq.gov/issue/preventable-deaths-patients-admitted-emergency-department
The authors re…
-
psnet.ahrq.gov/node/38547/psn-pdf
April 08, 2009 - Mortality related to anaesthesia in France: analysis of
deaths related to airway complications.
April 8, 2009
Auroy Y, Benhamou D, Péquignot F, et al. Mortality related to anaesthesia in France: analysis of deaths
related to airway complications. Anaesthesia. 2009;64(4):366-70. doi:10.1111/j.1365-2044.2008.05792.x.…
-
psnet.ahrq.gov/node/35984/psn-pdf
January 02, 2017 - The clinical transformation of Ascension Health:
eliminating all preventable injuries and deaths.
January 2, 2017
Pryor DB, Tolchin SF, Hendrich A, et al. The clinical transformation of Ascension Health: eliminating all
preventable injuries and deaths. Jt Comm J Qual Patient Saf. 2006;32(6):299-308.
https://psnet.…
-
psnet.ahrq.gov/node/41537/psn-pdf
December 30, 2014 - Deaths due to medical error: jumbo jets or just small
propeller planes?
December 30, 2014
Shojania KG. Deaths due to medical error: jumbo jets or just small propeller planes? BMJ Qual Saf.
2012;21(9). doi:10.1136/bmjqs-2012-001368.
https://psnet.ahrq.gov/issue/deaths-due-medical-error-jumbo-jets-or-just-small-prop…
-
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…
-
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…
-
psnet.ahrq.gov/node/43230/psn-pdf
July 15, 2014 - Hospital deaths in patients with sepsis from 2
independent cohorts.
July 15, 2014
Liu V, Escobar GJ, Greene JD, et al. Hospital deaths in patients with sepsis from 2 independent cohorts.
JAMA. 2014;312(1):90-2.
https://psnet.ahrq.gov/issue/hospital-deaths-patients-sepsis-2-independent-cohorts
This study used nati…
-
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…
-
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…
-
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…
-
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…