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psnet.ahrq.gov/node/43506/psn-pdf
September 10, 2014 - Review of Alleged Patient Deaths, Patient Wait Times, and
Scheduling Practices at the Phoenix VA Health Care
System.
September 10, 2014
Washington, DC: VA Office of the Inspector General; August 26, 2014. Report No.14-02603-267.
https://psnet.ahrq.gov/issue/review-alleged-patient-deaths-patient-wait-times-and-sche…
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psnet.ahrq.gov/node/41079/psn-pdf
October 16, 2012 - Effects of nurse staffing and nurse education on patient
deaths in hospitals with different nurse work
environments.
October 16, 2012
Aiken LH, Cimiotti JP, Sloane DM, et al. Effects of nurse staffing and nurse education on patient deaths in
hospitals with different nurse work environments. Med Care. 2011;49(12):1…
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psnet.ahrq.gov/node/36383/psn-pdf
March 03, 2011 - Patterns of errors contributing to trauma mortality:
lessons learned from 2,594 deaths.
March 3, 2011
Gruen RL, Jurkovich GJ, McIntyre LK, et al. Patterns of Errors Contributing to Trauma Mortality.
Transactions of the .. Meeting of the American Surgical Association. 2006;124.
doi:10.1097/01.sla.0000234655.83517.5…
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psnet.ahrq.gov/node/44586/psn-pdf
June 21, 2016 - 2013 Annual Hospital-Acquired Condition Rate and
Estimates of Cost Savings and Deaths Averted From 2010
to 2013.
June 21, 2016
Rockville, MD: Agency for Healthcare Research and Quality; October 2015. AHRQ Publication No.16-
0006-EF.
https://psnet.ahrq.gov/issue/2013-annual-hospital-acquired-condition-rate-and-est…
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psnet.ahrq.gov/node/37441/psn-pdf
November 01, 2012 - Saving Mothers' Lives: Reviewing Maternal Deaths to
Make Motherhood Safer—2003–2005.
November 1, 2012
Lewis G, ed. London, England: Confidential Enquiry into Maternal and Child Health; 2007. ISBN:
9780953353682.
https://psnet.ahrq.gov/issue/saving-mothers-lives-reviewing-maternal-deaths-make-motherhood-safer-
200…
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psnet.ahrq.gov/node/42734/psn-pdf
November 13, 2013 - Healthcare Inspection—Emergency Department Patient
Deaths: Memphis VAMC, Memphis, Tennessee.
November 13, 2013
Washington, DC: Department of Veterans Affairs, Office of Inspector General; October 23, 2013. Report
No. 13-00505-348.
https://psnet.ahrq.gov/issue/healthcare-inspection-emergency-department-patient-deat…
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psnet.ahrq.gov/node/35186/psn-pdf
July 13, 2005 - Saving lives: hospitals have signed on to a six-part plan
to avoid a multitude of unnecessary deaths.
July 13, 2005
Comarow A. US News & World Report. July 2005
https://psnet.ahrq.gov/issue/saving-lives-hospitals-have-signed-six-part-plan-avoid-multitude-unnecessary-
deaths
This article, accompanying the widely r…
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psnet.ahrq.gov/node/44701/psn-pdf
June 07, 2016 - The problem with preventable deaths.
June 7, 2016
Hogan H. The problem with preventable deaths. BMJ Qual Saf. 2016;25(5):320-3. doi:10.1136/bmjqs-
2015-004983.
https://psnet.ahrq.gov/issue/problem-preventable-deaths
A key goal of patient safety improvement is preventing error, but challenges remain in distinguishi…
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psnet.ahrq.gov/node/38783/psn-pdf
September 02, 2009 - Medical negligence in drug associated deaths.
September 2, 2009
Madea B, Musshoff F, Preuss J. Medical negligence in drug associated deaths. Forensic Sci Int.
2009;190(1-3):67-73. doi:10.1016/j.forsciint.2009.05.014.
https://psnet.ahrq.gov/issue/medical-negligence-drug-associated-deaths
This study reports that acc…
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psnet.ahrq.gov/node/47526/psn-pdf
January 16, 2019 - US national trends in pediatric deaths from prescription
and illicit opioids, 1999–2016.
January 16, 2019
Gaither JR, Shabanova V, Leventhal JM. US National Trends in Pediatric Deaths From Prescription and
Illicit Opioids, 1999-2016. JAMA Netw Open. 2018;1(8):e186558.
doi:10.1001/jamanetworkopen.2018.6558.
https:…
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psnet.ahrq.gov/node/46249/psn-pdf
July 12, 2017 - Zero preventable deaths after traumatic injury: an
achievable goal.
July 12, 2017
Spinella PC. Zero preventable deaths after traumatic injury. J Trauma Acute Care Surg. 2017;82:S2-S8.
doi:10.1097/ta.0000000000001425.
https://psnet.ahrq.gov/issue/zero-preventable-deaths-after-traumatic-injury-achievable-goal
Criti…
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psnet.ahrq.gov/node/47204/psn-pdf
July 18, 2018 - The burden of opioid-related mortality in the United
States.
July 18, 2018
Gomes T, Tadrous M, Mamdani MM, et al. The burden of opioid-related mortality in the United States.
JAMA Netw Open. 2018;1(2):e180217. doi:10.1001/jamanetworkopen.2018.0217.
https://psnet.ahrq.gov/issue/burden-opioid-related-mortality-unite…
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psnet.ahrq.gov/node/837909/psn-pdf
August 24, 2022 - Algorithm that detects sepsis cut deaths by nearly 20
percent.
August 24, 2022
Bushwick S. Scientific American. August 1, 2022.
https://psnet.ahrq.gov/issue/algorithm-detects-sepsis-cut-deaths-nearly-20-percent
Sepsis identification is challenging, and delays can be deadly. This article discusses how an artificial…
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psnet.ahrq.gov/node/60284/psn-pdf
April 29, 2020 - Trends in Pregnancy-Related Deaths and Federal Efforts
to Reduce Them.
April 29, 2020
Washington, DC: United States Government Accountability Office; March 2020. Publication GAO-20-
248.
https://psnet.ahrq.gov/issue/trends-pregnancy-related-deaths-and-federal-efforts-reduce-them
Maternal harm is a sentinel e…
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psnet.ahrq.gov/node/845655/psn-pdf
March 08, 2023 - Crisis in the Lakeshore Hospital ER.
March 8, 2023
Derfel A. Montreal Gazette. February 24- March 1, 2023
https://psnet.ahrq.gov/issue/crisis-lakeshore-hospital-er
Emergency room failures are often rooted in system weaknesses. This series examines six patient deaths
associated with emergency care that, w…
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psnet.ahrq.gov/node/838645/psn-pdf
January 19, 2022 - LeDeR - Learning from Lives and Deaths.
January 19, 2022
Norah Frye Centre for Disability Studies; Bristol, England.
https://psnet.ahrq.gov/issue/leder-learning-lives-and-deaths
People with a Learning Disability and autistic people (LeDeR) is a National Health Service-sponsored
initiative that seeks to improve the…
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psnet.ahrq.gov/node/35102/psn-pdf
November 04, 2015 - Plan aims to cut hospital deaths.
November 4, 2015
Appleby J.
https://psnet.ahrq.gov/issue/plan-aims-cut-hospital-deaths
This article reports on the 100,000 Lives Campaign and its mission, highlighting improvements in two
hospitals that have joined the campaign.
https://psnet.ahrq.gov/issue/plan-aims-cut-hospital…
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psnet.ahrq.gov/node/45473/psn-pdf
April 24, 2018 - Navigating a ship with a broken compass: evaluating
standard algorithms to measure patient safety.
April 24, 2018
Hefner JL, Huerta T, McAlearney AS, et al. Navigating a ship with a broken compass: evaluating standard
algorithms to measure patient safety. J Am Med Inform Assoc. 2017;24(2):310-315.
doi:10.1093/jami…
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psnet.ahrq.gov/node/39777/psn-pdf
November 04, 2012 - The Economic Measurement of Medical Errors.
November 4, 2012
Shreve J, van Den Bos J, Gray T, Halford M, Rustagi K, Ziemkiewicz E. Schaumburg, IL: The Society of
Actuaries; 2010.
https://psnet.ahrq.gov/issue/economic-measurement-medical-errors
Although the Institute of Medicine's estimate of up to 98,000 deaths ye…
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psnet.ahrq.gov/node/44349/psn-pdf
July 22, 2015 - Popular blood thinner causing deaths, injuries in nursing
homes.
July 22, 2015
https://psnet.ahrq.gov/issue/popular-blood-thinner-causing-deaths-injuries-nursing-homes
Anticoagulants are considered high-alert medications that if used ineffectively can result in patient harm.
Reporting on an anticoagulant commonly …