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psnet.ahrq.gov/node/33656/psn-pdf
September 01, 2007 - bypass surgeries that in the last decade have exploded in number and have caused unacceptable rates of
death
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psnet.ahrq.gov/periodic-issue/periodic-issue-305
August 25, 2021 - from disrespect and premature closure that resulted in missed diagnosis, unnecessary care, and patient death
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psnet.ahrq.gov/periodic-issue/periodic-issue-337
April 27, 2022 - The recent conviction of a nurse involved in the death of a patient has raised concerns that clinicians
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psnet.ahrq.gov/periodic-issue/periodic-issue-418
November 29, 2023 - WebM&M Cases
Medication Mix-Up Leads to Patient Death Luciano Sanchez, PharmD and Patrick Romano
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psnet.ahrq.gov/periodic-issue/periodic-issue-414
October 31, 2023 - editorials and opinion pieces discuss “Martha’s Rule,” a new policy in the United Kingdom motivated by the death
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psnet.ahrq.gov/periodic-issue/periodic-issue-417
November 29, 2023 - WebM&M Cases
Medication Mix-Up Leads to Patient Death Luciano Sanchez, PharmD and Patrick Romano
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psnet.ahrq.gov/periodic-issue/periodic-issue-398
July 31, 2023 - Death of a patient by suicide is a sentinel event.
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psnet.ahrq.gov/periodic-issue/periodic-issue-419
November 29, 2023 - WebM&M Cases
Medication Mix-Up Leads to Patient Death Luciano Sanchez, PharmD and Patrick Romano
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psnet.ahrq.gov/periodic-issue/periodic-issue-429
February 28, 2024 - WebM&M Cases
When Vomit Gets in the Way: Aspiration Resulting in Death During Endoscopy Timothy
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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/web-mm/discharging-our-responsibility
January 16, 2019 - Patients receiving the education intervention had a 35% lower risk of rehospitalization or death.
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psnet.ahrq.gov/web-mm/safety-challenges-supervision-and-night-coverage-academic-residency
February 21, 2024 - not notified of the patient's change in clinical status overnight and did not learn of the patient's death
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psnet.ahrq.gov/web-mm/undetected-foreign-object
April 24, 2018 - Unexpected autoptic finding in a sudden death: gossypiboma. Forensic Sci Int. 2010;199:e23-e26.
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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/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/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/techno-trip
May 01, 2005 - Pain pump study says patients at death risk. The Medical Post Web site. April 8, 2003.
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psnet.ahrq.gov/web-mm/resuscitation-errors-shocking-problem
October 19, 2022 - Sudden cardiac arrest (SCA) is a leading cause of death worldwide, claiming more than 300,000 lives each
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psnet.ahrq.gov/node/854897/psn-pdf
October 31, 2023 - process, from prescribing to administration, and can result in
various levels of harms, including 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