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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.269_slideshow.ppt
June 01, 2012 - about the events at the referring hospital and that such knowledge could have potentially prevented her death
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psnet.ahrq.gov/node/49795/psn-pdf
June 01, 2017 - life-threatening condition led to profound worsening of
the patient's condition and, ultimately, his death
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psnet.ahrq.gov/web-mm/real-heartache
October 01, 2018 - Whether or not the death of this patient could have been prevented is conjecture, but further consideration
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psnet.ahrq.gov/web-mm/discharge-against-medical-advice
July 01, 2017 - It is uncertain whether patients leaving the hospital AMA face an increased risk of death, as no study
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psnet.ahrq.gov/node/49544/psn-pdf
September 01, 2007 - Patients
receiving the education intervention had a 35% lower risk of rehospitalization or death.
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psnet.ahrq.gov/web-mm/case-patient-flow-management
February 23, 2019 - Problematic access and poor time management contributed to the death of this patient.
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psnet.ahrq.gov/node/73953/psn-pdf
October 27, 2021 - Association between polypharmacy and death: a
systematic review and meta-analysis.
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psnet.ahrq.gov/web-mm/two-wrongs-dont-make-right-kidney
April 01, 2010 - Wrong-site surgery has long been recognized as a sentinel event—an unexpected occurrence involving death
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psnet.ahrq.gov/web-mm/double-trouble
August 01, 2012 - this study, 17% of the post-discharge adverse events required rehospitalization and 3% resulted in death
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psnet.ahrq.gov/node/837659/psn-pdf
July 08, 2022 - Class 5 Moribund patients not expected to survive 24 hours with or without operation
ASA Class 6 Brain death
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psnet.ahrq.gov/node/49829/psn-pdf
May 01, 2018 - The practice of RCA for sentinel events (e.g., incidents resulting
in death, permanent harm, or severe
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psnet.ahrq.gov/node/846563/psn-pdf
March 21, 2023 - criminally negligent homicide and abuse of an impaired adult when
a medication error resulted in a patient death
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psnet.ahrq.gov/node/846768/psn-pdf
March 29, 2023 - metabolic syndrome, type 2 diabetes mellitus, non-alcoholic fatty liver disease, cancer and
premature death
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psnet.ahrq.gov/web-mm/slow-down-right-drug-wrong-formulation
October 13, 2018 - metoprolol tartrate at that dose was a prescribing error believed to have contributed to the patient's death
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psnet.ahrq.gov/curated-library/patient-and-family-engagement-long-term-care
April 10, 2024 - specifically lead to patient harm), and adverse events (harms due to medical care) are leading causes of death
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psnet.ahrq.gov/web-mm/norepinephrine-dosing-error-associated-multiple-health-system-vulnerabilities
November 27, 2019 - Within 9 hours of admission the patient’s hemodynamic lability progressed to cardiac arrest and death
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psnet.ahrq.gov/node/846935/psn-pdf
March 29, 2023 - Maternal Safety and Perinatal Mental Health
March 29, 2023
Allen C, Van CM, Mossburg S. Maternal Safety and Perinatal Mental Health . PSNet [internet]. 2023.
https://psnet.ahrq.gov/perspective/maternal-safety-and-perinatal-mental-health
Maternal patient safety is a critical aspect of healthcare given the complex pr…
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psnet.ahrq.gov/perspective/patient-safety-and-evolution-webmm-and-psnet
April 01, 2008 - Patient Safety and the Evolution of WebM&M and PSNet
September 1, 2019
View more articles from the same authors.
Citation Text:
Ranji SR, Wachter R. Patient Safety and the Evolution of WebM&M and PSNet. PSNet [internet]. Rockville (MD): Agency for Healthcare Resea…
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psnet.ahrq.gov/node/49586/psn-pdf
May 01, 2009 - Vial Mistakes Involving Heparin
May 1, 2009
Vanderveen T. Vial Mistakes Involving Heparin. PSNet [internet]. 2009.
https://psnet.ahrq.gov/web-mm/vial-mistakes-involving-heparin
The Case
A 65-year-old man was admitted to the hospital for an elective left carotid endarterectomy. During the
procedure, the surgeon re…
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psnet.ahrq.gov/web-mm/mixup-beyond-medication-label
June 01, 2014 - Mixup Beyond the Medication Label
Citation Text:
Pervanas H, VanValkenburgh D. Mixup Beyond the Medication Label. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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