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psnet.ahrq.gov/node/49552/psn-pdf
January 01, 2008 - errors for which the provider feels directly and fully
responsible, and those that result in patient death
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psnet.ahrq.gov/node/836841/psn-pdf
June 01, 2020 - the 101 home visit patients showed no differences in readmissions, emergency department
visits, or death
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psnet.ahrq.gov/node/49798/psn-pdf
July 01, 2017 - peritonitis, sepsis, and multi-organ failure progressed
postoperatively, ultimately leading to the death
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psnet.ahrq.gov/node/50949/psn-pdf
February 26, 2020 - hour delay in treatment of severe infections, such as sepsis, exponentially increases
the odds of death
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psnet.ahrq.gov/node/49584/psn-pdf
April 01, 2009 - as EMRs and interoperability grow,
identity errors will increase, causing more avoidable errors and death
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psnet.ahrq.gov/perspective/impact-system-failures-healthcare-workers
August 30, 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/web-mm/weight-and-height-juxtaposition-electronic-medical-record-causing-accidental-medication
March 15, 2023 - process , from prescribing to administration, and can result in various levels of harms, including death
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psnet.ahrq.gov/node/49760/psn-pdf
May 01, 2016 - permanent cognitive decline, prolonged hospitalization, re-
hospitalization, nursing home placement, and death
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psnet.ahrq.gov/node/33723/psn-pdf
December 01, 2011 - For
patients already ill enough to require hospitalization, the likelihood of an injury resulting in death
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psnet.ahrq.gov/node/49567/psn-pdf
September 01, 2008 - Legionella pneumophilia infection induces programmed cell death,
capsase activation, and release of
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psnet.ahrq.gov/primer/burnout
November 20, 2024 - Death by 1000 Cuts: Medscape National Physician Burnout & Suicide Report 2021. Medscape .
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psnet.ahrq.gov/primer/deprescribing-patient-safety-strategy
December 15, 2024 - Association between polypharmacy and death: a systematic review and meta-analysis.
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psnet.ahrq.gov/web-mm/danger-10-intravenous-calcium-chloride-extravasation
April 24, 2024 - WebM&M Cases
Medication Mix-Up Leads to Patient Death
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psnet.ahrq.gov/web-mm/discharge-fumbles
September 09, 2009 - controlled trial assessing the efficacy of an electronic discharge communication tool for preventing death
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psnet.ahrq.gov/web-mm/root-cause-analysis-gone-wrong
August 28, 2024 - The practice of RCA for sentinel events (e.g., incidents resulting in death, permanent harm, or severe
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psnet.ahrq.gov/sites/default/files/2024-07/spotlight_case_mismanagement_of_acute_decompensated_heart_failure_slides_final.pptx
January 01, 2024 - rates of late critical care admission, late intubation, late renal replacement therapy, and in-hospital death
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psnet.ahrq.gov/web-mm/communication-failure-whos-charge
April 01, 2018 - model ( 7,8 ), much less a team mental model.( 9 ) Said another way, this child's arrest and subsequent death
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psnet.ahrq.gov/web-mm/communication-error-closed-icu
July 01, 2016 - transplant—a conversation that may have averted the complication that contributed to the patient's death
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psnet.ahrq.gov/web-mm/code-status-confusion
September 01, 2006 - Make clear the alternative to CPR is death, and express, quantitatively or qualitatively, the likely
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psnet.ahrq.gov/web-mm/techno-trip
May 01, 2005 - Pain pump study says patients at death risk. The Medical Post Web site. April 8, 2003.