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psnet.ahrq.gov/web-mm/medication-mix-bad-worse
March 01, 2018 - Consequences of LASA errors can range from no patient harm to death.
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psnet.ahrq.gov/web-mm/delay-initiating-antibiotics-results-fatal-error
August 02, 2015 - Serious adverse outcomes occurred in 90% of the cases, including death in 31% of cases.
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psnet.ahrq.gov/web-mm/perils-contrast-media
March 01, 2007 - life-threatening condition led to profound worsening of the patient's condition and, ultimately, his death
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psnet.ahrq.gov/node/863650/psn-pdf
February 28, 2024 - that experiencing two or more adverse events was associated with
a threefold increase in the risk of death
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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/sites/default/files/2024-10/spotlight_case_a_cognitive_and_communication_blind_spot_slides.pptx
January 01, 2024 - may lack a thorough understanding of how critical changes can quickly result in otherwise preventable death
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psnet.ahrq.gov/web-mm/who-nose-where-airway
May 01, 2016 - The device was lodged within the trachea and right bronchus.( 1 ) One death was reported in a case with
-
psnet.ahrq.gov/node/838855/psn-pdf
October 27, 2022 - requiring only monitoring to “tension” pneumothorax with acute respiratory failure,
shock, and even death
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psnet.ahrq.gov/node/841139/psn-pdf
December 14, 2022 - probably require other operations in the future and that
mismanagement of her airway could lead to her death
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psnet.ahrq.gov/node/60269/psn-pdf
April 29, 2020 - In necrotizing infections, these surgical cut-downs will reveal tissue ischemia and death,
with a pathognomonic
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psnet.ahrq.gov/node/49669/psn-pdf
November 01, 2012 - The rates of in-hospital death or
acute coronary syndrome were also not statistically significant between
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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/node/860050/psn-pdf
January 04, 2024 - abusive head trauma cases were missed, and that 28% of those
missed cases led to re-injury and 9% led to death
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psnet.ahrq.gov/node/49639/psn-pdf
November 01, 2011 - However, it has been estimated that
for each preventable death, there are between 7–100 close calls
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psnet.ahrq.gov/sites/default/files/2020-12/final_dec_spotlight_code_status_vs_care_status.pdf
January 01, 2020 - Effect of ICU strain on timing of limitations in life-sustaining therapy and on death.
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psnet.ahrq.gov/node/73456/psn-pdf
June 30, 2021 - Even though this problem occurs rarely, brain damage and death attributed to difficult airway
management
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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/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/cvc-placement-speak-now-or-do-not-use-line
November 01, 2003 - to patient safety and, in the case of a newly placed CVC, can mean the difference between life and 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