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psnet.ahrq.gov/node/846764/psn-pdf
March 29, 2023 - Senators threaten consequences after VA confirms 4
deaths tied to computer system tested in Spokane.
March 29, 2023
Donovan-Smith O. Spokesman Review. March 15, 2023.
https://psnet.ahrq.gov/issue/senators-threaten-consequences-after-va-confirms-4-deaths-tied-computer-
system-tested-spokane
Implementations of elec…
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psnet.ahrq.gov/node/47154/psn-pdf
May 23, 2018 - Comparison of military and civilian methods for
determining potentially preventable deaths: a systematic
review.
May 23, 2018
Janak JC, Sosnov JA, Bares JM, et al. Comparison of Military and Civilian Methods for Determining
Potentially Preventable Deaths: A Systematic Review. JAMA Surg. 2018;153(4):367-375.
doi:1…
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psnet.ahrq.gov/node/46899/psn-pdf
March 21, 2018 - Patient Deaths at Arbour Health Systems—Westwood
Lodge Hospital and Pembroke Hospital.
March 21, 2018
Disability Law Center. Boston, MA: February 2018.
https://psnet.ahrq.gov/issue/patient-deaths-arbour-health-systems-westwood-lodge-hospital-and-
pembroke-hospital
Patients with mental health concerns are vulnerab…
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psnet.ahrq.gov/node/47333/psn-pdf
October 10, 2018 - Changing dynamics of the drug overdose epidemic in the
United States from 1979 through 2016.
October 10, 2018
Jalal H, Buchanich JM, Roberts MS, et al. Changing dynamics of the drug overdose epidemic in the United
States from 1979 through 2016. Science (1979). 2018;361(6408). doi:10.1126/science.aau1184.
https://p…
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psnet.ahrq.gov/node/43253/psn-pdf
May 01, 2015 - Interim Report: Review of VHA's Patient Wait Times,
Scheduling Practices, and Alleged Patient Deaths at the
Phoenix Health Care System.
May 1, 2015
Washington, DC: VA Office of the Inspector General; May 28, 2014. Report No. 14-02603-178.
https://psnet.ahrq.gov/issue/interim-report-review-vhas-patient-wait-times-s…
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psnet.ahrq.gov/node/35365/psn-pdf
February 17, 2011 - Accidental deaths, saved lives, and improved quality.
February 17, 2011
Brennan TA, Gawande AA, Thomas EJ, et al. Accidental Deaths, Saved Lives, and Improved Quality. New
England Journal of Medicine. 2005;353(13). doi:10.1056/nejmsb051157.
https://psnet.ahrq.gov/issue/accidental-deaths-saved-lives-and-improved-qua…
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psnet.ahrq.gov/node/45862/psn-pdf
February 08, 2017 - Learning, Candour and Accountability. A Review of the
Way NHS Trusts Review and Investigate the Deaths of
Patients in England.
February 8, 2017
Newcastle Upon Tyne, UK: Care Quality Commission; December 2016. CQC-356-122016.
https://psnet.ahrq.gov/issue/learning-candour-and-accountability-review-way-nhs-trusts-rev…
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psnet.ahrq.gov/node/36298/psn-pdf
September 27, 2006 - Hospital Reporting of Deaths Related to Restraint and
Seclusion.
September 27, 2006
Levinson DR. Washington DC: Office of the Inspector General; September 2006. OEI-09-04-00350
https://psnet.ahrq.gov/issue/hospital-reporting-deaths-related-restraint-and-seclusion
This report presents findings from an investigatio…
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psnet.ahrq.gov/node/43444/psn-pdf
August 27, 2014 - Patient-safety–related hospital deaths in England:
thematic analysis of incidents reported to a national
database, 2010–2012.
August 27, 2014
Donaldson LJ, Panesar S, Darzi A. Patient-safety-related hospital deaths in England: thematic analysis of
incidents reported to a national database, 2010-2012. PLoS Med. 201…
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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/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/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/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/47211/psn-pdf
November 16, 2018 - A conceptual framework to reduce inpatient preventable
deaths.
November 16, 2018
Davis DP, Aguilar SA, Lawrence B, et al. A Conceptual Framework to Reduce Inpatient Preventable
Deaths. Jt Comm J Qual Patient Saf. 2018;44(7):413-420. doi:10.1016/j.jcjq.2018.01.003.
https://psnet.ahrq.gov/issue/conceptual-framework-…
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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/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…