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psnet.ahrq.gov/node/36726/psn-pdf
January 22, 2017 - Eliminating preventable death at Ascension Health. … Eliminating preventable death at Ascension Health. Jt Comm J Qual
Patient Saf. 2007;33(3):145-54. … https://psnet.ahrq.gov/issue/eliminating-preventable-death-ascension-health
The authors report the results … https://psnet.ahrq.gov/issue/eliminating-preventable-death-ascension-health
https://psnet.ahrq.gov//#
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psnet.ahrq.gov/issue/maternal-deaths-metrowest-hospital-prompt-state-probes
August 24, 2016 - Maternal death is a sentinel event . … November 21, 2007
MGH death spurs review of patient monitors. … June 8, 2011
'Alarm fatigue’ a factor in 2nd death.
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qualityindicators.ahrq.gov/Downloads/Modules/QI_Reporting/Model_Report_Health_Topics.pdf
January 01, 2000 - Death rates should be extremely low. … Death rate for patients with health problems that rarely result in death
How often patients … health
problems that rarely result in death
The average rate of death for hospitals
across the state … (This is called death in low mortality DRGs.) … Death rate for patients with health problems
that rarely result in death
15
12
6
3
1
0 10 20
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psnet.ahrq.gov/node/60809/psn-pdf
August 12, 2020 - Avoiding care during the pandemic could mean life or
death.
August 12, 2020
Glionna JM. … https://psnet.ahrq.gov/issue/avoiding-care-during-pandemic-could-mean-life-or-death
The reluctance of … https://psnet.ahrq.gov/issue/avoiding-care-during-pandemic-could-mean-life-or-death
https://psnet.ahrq.gov
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psnet.ahrq.gov/node/50667/psn-pdf
November 13, 2019 - Proactive prevention of maternal death from maternal
hemorrhage.
November 13, 2019
Quick Safety. … https://psnet.ahrq.gov/issue/proactive-prevention-maternal-death-maternal-hemorrhage
The reduction of … https://psnet.ahrq.gov/issue/proactive-prevention-maternal-death-maternal-hemorrhage
http://psnet.ahrq.gov
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psnet.ahrq.gov/node/46550/psn-pdf
November 15, 2017 - "It's the difference between life and death": the views of
professional medical interpreters on their … "It's the difference between life and death": The views of professional medical
interpreters on their … https://psnet.ahrq.gov/issue/its-difference-between-life-and-death-views-professional-medical-interpreters … https://psnet.ahrq.gov/issue/its-difference-between-life-and-death-views-professional-medical-interpreters-their-role … https://psnet.ahrq.gov/issue/its-difference-between-life-and-death-views-professional-medical-interpreters-their-role
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psnet.ahrq.gov/node/41601/psn-pdf
August 15, 2012 - The short life and lonely death of Sabrina Seelig.
August 15, 2012
Hartocollis A. … https://psnet.ahrq.gov/issue/short-life-and-lonely-death-sabrina-seelig
This newspaper article reports … on the missteps that contributed to the death of a young woman after she
was hospitalized in an incident … https://psnet.ahrq.gov/issue/short-life-and-lonely-death-sabrina-seelig
https://psnet.ahrq.gov/issue/
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psnet.ahrq.gov/node/854264/psn-pdf
October 04, 2023 - Patient death tied to lack of proper escalation process for
barcode scanning failures. … https://psnet.ahrq.gov/issue/patient-death-tied-lack-proper-escalation-process-barcode-scanning-failures … https://psnet.ahrq.gov/issue/patient-death-tied-lack-proper-escalation-process-barcode-scanning-failures
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psnet.ahrq.gov/node/36078/psn-pdf
July 03, 2013 - Inquiry into reporter's death finds multiple failures in care.
July 3, 2013
Stout D. … https://psnet.ahrq.gov/issue/inquiry-reporters-death-finds-multiple-failures-care
This article reports … on the investigation following the death of New York Times reporter David E. … https://psnet.ahrq.gov/issue/inquiry-reporters-death-finds-multiple-failures-care
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psnet.ahrq.gov/node/41821/psn-pdf
November 07, 2012 - Death of a boy prompts new medical efforts nationwide.
November 7, 2012
Dwyer J. New York Times. … https://psnet.ahrq.gov/issue/death-boy-prompts-new-medical-efforts-nationwide
Reporting on the death … https://psnet.ahrq.gov/issue/death-boy-prompts-new-medical-efforts-nationwide
https://psnet.ahrq.gov/
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psnet.ahrq.gov/node/74119/psn-pdf
November 24, 2021 - When we're all responsible for a patient's death, no one
is. … https://psnet.ahrq.gov/issue/when-were-all-responsible-patients-death-no-one
The issue of system versus … https://psnet.ahrq.gov/issue/when-were-all-responsible-patients-death-no-one
https://psnet.ahrq.gov/issue
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psnet.ahrq.gov/node/35287/psn-pdf
June 30, 2009 - Surgical accountability in the 1880s: the death of Susan
Nixon. … Surgical accountability in the 1880s: the death of Susan Nixon. … https://psnet.ahrq.gov/issue/surgical-accountability-1880s-death-susan-nixon
Using an account of surgical … https://psnet.ahrq.gov/issue/surgical-accountability-1880s-death-susan-nixon
https://psnet.ahrq.gov//
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psnet.ahrq.gov/issue/ranking-hospitals-avoidable-death-rates-derived-retrospective-case-record-review
August 10, 2022 - Commentary
Ranking hospitals on avoidable death rates derived from retrospective … Ranking hospitals on avoidable death rates derived from retrospective case record review: methodological … Ranking hospitals on avoidable death rates derived from retrospective case record review: methodological … View More
Related Resources
Ranking hospitals based on preventable hospital death
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psnet.ahrq.gov/node/37075/psn-pdf
October 03, 2011 - Outreach and Early Warning Systems (EWS) for the
prevention of Intensive Care admission and death of … Outreach and Early Warning Systems (EWS) for the
prevention of Intensive Care admission and death of … psnet.ahrq.gov/issue/outreach-and-early-warning-systems-ews-prevention-intensive-care-
admission-and-death … psnet.ahrq.gov/issue/outreach-and-early-warning-systems-ews-prevention-intensive-care-admission-and-death … psnet.ahrq.gov/issue/outreach-and-early-warning-systems-ews-prevention-intensive-care-admission-and-death
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psnet.ahrq.gov/node/44025/psn-pdf
February 22, 2018 - The causes of their death appear (unto our shame
perpetual): why root cause analysis is not the best … The Causes of Their Death Appear (Unto Our Shame Perpetual):
Why Root Cause Analysis Is Not the Best … https://psnet.ahrq.gov/issue/causes-their-death-appear-unto-our-shame-perpetual-why-root-cause-
analysis-not-best-model … https://psnet.ahrq.gov/issue/causes-their-death-appear-unto-our-shame-perpetual-why-root-cause-analysis-not-best-model … https://psnet.ahrq.gov/issue/causes-their-death-appear-unto-our-shame-perpetual-why-root-cause-analysis-not-best-model
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psnet.ahrq.gov/node/43871/psn-pdf
March 17, 2015 - FDA begins inquiry after death and illness from saline
bags meant for training. … https://psnet.ahrq.gov/issue/fda-begins-inquiry-after-death-and-illness-saline-bags-meant-training
This … training purposes was inadvertently distributed and used for actual care and led to patient
harm and death … https://psnet.ahrq.gov/issue/fda-begins-inquiry-after-death-and-illness-saline-bags-meant-training
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psnet.ahrq.gov/node/34622/psn-pdf
March 17, 2011 - National Confidential Enquiry into Patient Outcome and
Death. … March 17, 2011
National Confidential Enquiry into Patient Outcome and Death; NCEPOD
https://psnet.ahrq.gov … /issue/national-confidential-enquiry-patient-outcome-and-death
Launched under the title National Confidential … https://psnet.ahrq.gov/issue/national-confidential-enquiry-patient-outcome-and-death
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psnet.ahrq.gov/node/38336/psn-pdf
January 14, 2009 - Proceedings of a summit on preventing patient harm and
death from IV medication errors. … January 14, 2009
Proceedings of a summit on preventing patient harm and death from i.v. medication errors … https://psnet.ahrq.gov/issue/proceedings-summit-preventing-patient-harm-and-death-iv-medication-errors … https://psnet.ahrq.gov/issue/proceedings-summit-preventing-patient-harm-and-death-iv-medication-errors
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psnet.ahrq.gov/node/43003/psn-pdf
March 05, 2014 - Learning from every death.
March 5, 2014
Huddleston JM, Diedrich DA, Kinsey GC, et al. … Learning from every death. J Patient Saf. 2014;10(1):6-12.
doi:10.1097/PTS.0000000000000053. … https://psnet.ahrq.gov/issue/learning-every-death
This commentary describes how design and implementation … https://psnet.ahrq.gov/issue/learning-every-death
https://psnet.ahrq.gov/issue/saving-lives-studying-deaths-using-standardized-mortality-reviews-improve-inpatient-safety
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effectivehealthcare-admin.ahrq.gov/products/antipsychotic-medicine-cardiovascular-elderly/research
January 01, 2020 - Risk of death in elderly users of conventional vs. atypical antipsychotic medications. … Antipsychotics and the risk of sudden cardiac death. … Thioridazine and sudden unexplained death in psychiatric inpatients. … Antipsychotics and the risk of sudden cardiac death. Arch Gen Psychiatry 2001;58:1161-1167.
36. … Antipsychotic drugs: prolonged QTc Interval, Torsade de Pointes, and sudden death.