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psnet.ahrq.gov/issue/preventing-maternal-death
March 27, 2024 - Sentinel Event Alerts
Preventing maternal death. … Citation Text:
Preventing maternal death. Sentinel Event Alert. 2010;44(44):1-4. … This recently retired alert targets prevention of maternal death and highlights the need to manage blood … URL
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Preventing maternal death
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psnet.ahrq.gov/issue/death-handwriting
October 19, 2022 - Newspaper/Magazine Article
Death by handwriting. … Death by handwriting. Trustee : the journal for hospital governing boards. 2005;58(9):29-32. … Death by handwriting. Trustee : the journal for hospital governing boards. 2005;58(9):29-32.
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psnet.ahrq.gov/web-mm/time-death
August 01, 2009 - Time of Death? … The code team never came together to discuss this error (the premature pronouncement of death); rather … too exhausted to continue A medical professional decides it’s time to stop, or Obvious signs of death … What apparent signs of death should be sought? … Video Video Title Length View 1 Time of Death 6:56
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psnet.ahrq.gov/web-mm/death-pca
November 05, 2014 - Death by PCA
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Facebook … effects, including pruritus, bradypnea, hypoxia, nausea, vomiting, sedation, urinary retention, and death … Programming errors contribute to death from patient-controlled analgesia: case report and estimate of
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psnet.ahrq.gov/issue/learning-every-death
August 05, 2009 - Commentary
Learning from every death. … Learning from every death. J Patient Saf. 2014;10(1):6-12. doi:10.1097/PTS.0000000000000053. … Learning from every death. J Patient Saf. 2014;10(1):6-12. doi:10.1097/PTS.0000000000000053.
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psnet.ahrq.gov/issue/slow-troubling-death-autopsy
August 19, 2020 - Newspaper/Magazine Article
The slow, troubling death of the autopsy. … The rate of autopsies – the “gold standard” of death investigation – are decreasing worldwide. … August 19, 2020
Race, postoperative complications, and death in apparently healthy children
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psnet.ahrq.gov/issue/state-nurse-error-caused-death
May 10, 2006 - Newspaper/Magazine Article
State: nurse error caused death. … This article reports on a federal warning issued to a hospital after a medication error led to the death … June 6, 2007
Inquiry into reporter's death finds multiple failures in care. … More
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Investigators find hospital error caused mother’s death
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psnet.ahrq.gov/issue/cause-death-sloppy-doctors
February 07, 2007 - Newspaper/Magazine Article
Cause of death: sloppy doctors. … January 28, 2015
FDA begins inquiry after death and illness from saline bags meant for … January 24, 2024
Investigators find hospital error caused mother’s death in Brooklyn. … April 3, 2019
Death by 1,000 clicks: where electronic health records went wrong.
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psnet.ahrq.gov/issue/arresting-death-saving-100000-lives
June 07, 2006 - Newspaper/Magazine Article
Arresting death: saving 100,000 lives. … Arresting death: saving 100,000 lives. Trustee. 2007;60(1):6-11. … Arresting death: saving 100,000 lives. Trustee. 2007;60(1):6-11.
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psnet.ahrq.gov/issue/government-response-investigation-death-elizabeth-dixon
November 16, 2022 - Book/Report
Government Response to the Investigation into the Death of Elizabeth … London, England: Crown Copyright; 2023
Following an investigation into the death of 11-month-old … July 22, 2020
The Life and Death of Elizabeth Dixon: A Catalyst for Change. … 'We had such trust, we feel such fools’: how shocking hospital mistakes led to our daughter’s death
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psnet.ahrq.gov/issue/alarm-fatigue-factor-2nd-death
February 23, 2011 - Newspaper/Magazine Article
'Alarm fatigue’ a factor in 2nd death. … Reporting on a patient death involving alarm fatigue , this newspaper article describes how one hospital … February 23, 2011
MGH death spurs review of patient monitors. … 2007
Doctor’s orders killed cancer patient: Dana-Farber admits drug overdose caused death
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psnet.ahrq.gov/issue/eliminating-preventable-death-ascension-health
June 03, 2020 - Commentary
Eliminating preventable death at Ascension Health. … Eliminating preventable death at Ascension Health. Jt Comm J Qual Patient Saf. 2007;33(3):145-54. … Eliminating preventable death at Ascension Health.
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psnet.ahrq.gov/issue/nurse-charged-death-patient
January 25, 2006 - Newspaper/Magazine Article
Nurse is charged in death of patient.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention-chronic-care/decision/mcc/kent_grant.pdf
September 01, 2013 - HF and CKD are both associated with an
increased risk of arrhythmic death as well as non-arrhythmic … death. … estimate how
variation in severity of HF and CKD affect the risk of cause-specific
mortality (sudden cardiac … death, non-arrhythmic cardiac death, and
non-cardiac mortality), and estimate the rates of CKD and … Risk of
arrhythmic and non-arrhythmic death in patients with heart failure and chronic kidney disease
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psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
March 01, 2004 - The death was unexpected, particularly given the patient's low preoperative risk, and the family and … The Commentary This patient's death certainly warrants the label "unexpected." … ) of less than 0.5%.( 2 ) What then should we infer from her unfortunate and unexpected death: chance … Using this framework, "death in low-mortality DRG" would score highly on clinical importance and (in … One can justify using an indicator like death in a low-mortality DRG as a screening test, that, when
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effectivehealthcare.ahrq.gov/products/carioverter-difibrillators/abstract
April 14, 2010 - ICDs provide meaningful prolongation of life for patients in clinical trials at high risk for sudden cardiac … death (SCD), data are lacking on the effectiveness of ICDs in patients who receive Medicare benefits … Research Objectives:
Aim 1: To demonstrate differences in the incidence rate of death and cardiovascular … Aim 2: To explore whether the incidence of death and cardiovascular hospitalizations after ICD implantation … Exposure(s): ICDs
Outcomes: The following are study outcomes: all-cause death, hospitalization for
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psnet.ahrq.gov/issue/lessons-learned-death-outside-hospitals-doorstep
October 30, 2019 - Newspaper/Magazine Article
Lessons learned from a death outside a hospital's doorstep … Reporting on lessons to be learned from the cascade of failures connected with the preventable death
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psnet.ahrq.gov/issue/organ-donors-surgery-death-sparks-questions
April 06, 2016 - Newspaper/Magazine Article
Organ donor's surgery death sparks questions. … This news article reports on errors that contributed to the death of a live organ donor and describes … November 25, 2009
Wife 'heartbroken' at death blamed on meningitis. … September 23, 2020
Avoiding care during the pandemic could mean life or death.
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psnet.ahrq.gov/issue/life-and-death-elizabeth-dixon-catalyst-change
November 16, 2022 - Book/Report
The Life and Death of Elizabeth Dixon: A Catalyst for Change. … inadequate clinician expertise were among the contributing factors identified in this analysis of the death … October 6, 2021
Government Response to the Investigation into the Death of Elizabeth … July 19, 2023
Government Response to the Investigation into the Death of Elizabeth Dixon
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psnet.ahrq.gov/issue/problem-preventable-deaths
May 19, 2021 - Commentary
The problem with preventable deaths.
Citation Text:
Hogan H. The problem with preventable deaths. BMJ Qual Saf. 2016;25(5):320-3. doi:10.1136/bmjqs-2015-004983.
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