-
www.monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4n_combo_iqi-mortalityreview-bestpractices.pdf
May 20, 2016 - sentinel events reported to the Joint Commission between 2004 and June
2013 resulted in a patient death … o Was the case an expected death?
Yes:
What was the condition on admission? … on admission but expected at the time of death? … associated with drug reaction
∗ Death associated with adverse drug reaction
∗ Death associated with … associated with drug reaction
∗ Death associated with adverse drug event
∗ Death related to medical
-
www.talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4n_combo_iqi-mortalityreview-bestpractices.pdf
May 20, 2016 - sentinel events reported to the Joint Commission between 2004 and June
2013 resulted in a patient death … o Was the case an expected death?
Yes:
What was the condition on admission? … on admission but expected at the time of death? … associated with drug reaction
∗ Death associated with adverse drug reaction
∗ Death associated with … associated with drug reaction
∗ Death associated with adverse drug event
∗ Death related to medical
-
www.qualitymeasures.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4n_combo_iqi-mortalityreview-bestpractices.pdf
May 20, 2016 - sentinel events reported to the Joint Commission between 2004 and June
2013 resulted in a patient death … o Was the case an expected death?
Yes:
What was the condition on admission? … on admission but expected at the time of death? … associated with drug reaction
∗ Death associated with adverse drug reaction
∗ Death associated with … associated with drug reaction
∗ Death associated with adverse drug event
∗ Death related to medical
-
teamstepps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4n_combo_iqi-mortalityreview-bestpractices.pdf
May 20, 2016 - sentinel events reported to the Joint Commission between 2004 and June
2013 resulted in a patient death … o Was the case an expected death?
Yes:
What was the condition on admission? … on admission but expected at the time of death? … associated with drug reaction
∗ Death associated with adverse drug reaction
∗ Death associated with … associated with drug reaction
∗ Death associated with adverse drug event
∗ Death related to medical
-
patientregistry.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4n_combo_iqi-mortalityreview-bestpractices.pdf
May 20, 2016 - sentinel events reported to the Joint Commission between 2004 and June
2013 resulted in a patient death … o Was the case an expected death?
Yes:
What was the condition on admission? … on admission but expected at the time of death? … associated with drug reaction
∗ Death associated with adverse drug reaction
∗ Death associated with … associated with drug reaction
∗ Death associated with adverse drug event
∗ Death related to medical
-
healthcare411.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4n_combo_iqi-mortalityreview-bestpractices.pdf
May 20, 2016 - sentinel events reported to the Joint Commission between 2004 and June
2013 resulted in a patient death … o Was the case an expected death?
Yes:
What was the condition on admission? … on admission but expected at the time of death? … associated with drug reaction
∗ Death associated with adverse drug reaction
∗ Death associated with … associated with drug reaction
∗ Death associated with adverse drug event
∗ Death related to medical
-
cahps.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4n_combo_iqi-mortalityreview-bestpractices.pdf
May 20, 2016 - sentinel events reported to the Joint Commission between 2004 and June
2013 resulted in a patient death … o Was the case an expected death?
Yes:
What was the condition on admission? … on admission but expected at the time of death? … associated with drug reaction
∗ Death associated with adverse drug reaction
∗ Death associated with … associated with drug reaction
∗ Death associated with adverse drug event
∗ Death related to medical
-
ahrqpubs.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4n_combo_iqi-mortalityreview-bestpractices.pdf
May 20, 2016 - sentinel events reported to the Joint Commission between 2004 and June
2013 resulted in a patient death … o Was the case an expected death?
Yes:
What was the condition on admission? … on admission but expected at the time of death? … associated with drug reaction
∗ Death associated with adverse drug reaction
∗ Death associated with … associated with drug reaction
∗ Death associated with adverse drug event
∗ Death related to medical
-
pbrn.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4n_combo_iqi-mortalityreview-bestpractices.pdf
May 20, 2016 - sentinel events reported to the Joint Commission between 2004 and June
2013 resulted in a patient death … o Was the case an expected death?
Yes:
What was the condition on admission? … on admission but expected at the time of death? … associated with drug reaction
∗ Death associated with adverse drug reaction
∗ Death associated with … associated with drug reaction
∗ Death associated with adverse drug event
∗ Death related to medical
-
pcmh.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4n_combo_iqi-mortalityreview-bestpractices.pdf
May 20, 2016 - sentinel events reported to the Joint Commission between 2004 and June
2013 resulted in a patient death … o Was the case an expected death?
Yes:
What was the condition on admission? … on admission but expected at the time of death? … associated with drug reaction
∗ Death associated with adverse drug reaction
∗ Death associated with … associated with drug reaction
∗ Death associated with adverse drug event
∗ Death related to medical
-
monahrq.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4n_combo_iqi-mortalityreview-bestpractices.pdf
May 20, 2016 - sentinel events reported to the Joint Commission between 2004 and June
2013 resulted in a patient death … o Was the case an expected death?
Yes:
What was the condition on admission? … on admission but expected at the time of death? … associated with drug reaction
∗ Death associated with adverse drug reaction
∗ Death associated with … associated with drug reaction
∗ Death associated with adverse drug event
∗ Death related to medical
-
talkingquality.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4n_combo_iqi-mortalityreview-bestpractices.pdf
May 20, 2016 - sentinel events reported to the Joint Commission between 2004 and June
2013 resulted in a patient death … o Was the case an expected death?
Yes:
What was the condition on admission? … on admission but expected at the time of death? … associated with drug reaction
∗ Death associated with adverse drug reaction
∗ Death associated with … associated with drug reaction
∗ Death associated with adverse drug event
∗ Death related to medical
-
ce.effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4n_combo_iqi-mortalityreview-bestpractices.pdf
May 20, 2016 - sentinel events reported to the Joint Commission between 2004 and June
2013 resulted in a patient death … o Was the case an expected death?
Yes:
What was the condition on admission? … on admission but expected at the time of death? … associated with drug reaction
∗ Death associated with adverse drug reaction
∗ Death associated with … associated with drug reaction
∗ Death associated with adverse drug event
∗ Death related to medical
-
www.uspreventiveservicestaskforce.org/uspstf/document/final-evidence-summary11/carotid-artery-stenosis-screening-december-2007
December 15, 2007 - This benefit includes an approximate 3% rate of perioperative stroke or death. … /stroke or death/stroke/myocardial infarction within 30 days of surgery. … A small increase in perioperative strokes or death could counteract the benefits. … Rate of CEA: Stroke/Death, MI
Results: any CVA & Perioper. … Stroke/death (95% CI)
Rate of Perioperative CVA/Death & Subseq. Ipsilat.
-
ce.effectivehealthcare.ahrq.gov/patient-safety/reports/liability/baker.html
August 01, 2017 - ; and intra-partum fetal death of full-term infant. … The final, selected events were: Shoulder Dystocia, Post-Partum Hemorrhage, Intra‑Partum Fetal Death … For example, three clinicians were surveyed regarding Intra-Partum Fetal Death due to Group B Strep, … Intra-Partum Fetal Death
Pre-Hospital
Clinician does not educate mother/family about risks
3.60 … Intra-Partum Fetal Death
Pre-Hospital
Clinician does not educate mother/family about risks
4.00
-
psnet.ahrq.gov/node/37048/psn-pdf
September 29, 2011 - //psnet.ahrq.gov/issue/when-my-father-died
The physician author recounts the story of her father's death—a … death that she feels was preventable and
caused, in part, by errors in judgment made during his care
-
psnet.ahrq.gov/node/46334/psn-pdf
August 09, 2017 - https://psnet.ahrq.gov/issue/maternal-deaths-metrowest-hospital-prompt-state-probes
Maternal death is … maternal-deaths-metrowest-hospital-prompt-state-probes
https://psnet.ahrq.gov/issue/preventing-maternal-death
-
psnet.ahrq.gov/node/34639/psn-pdf
March 02, 2011 - Clinical experts then prepared discharge summaries, including an opinion on whether a death
was preventable
-
hcup-us.ahrq.gov/datainnovations/raceethnicitytoolkit/or31.jsp
August 01, 2014 - mortality among AI/ANs
AI/AN life span 6 years below U.S. average
After declining in 1900s, AI/AN death … become a public health priority area for Indian Country
Slide 4
AI/AN race often misclassified on death … Cancer registries
Hospital discharge systems
Death certificates
STD/HIV and other communicable … likelihood of a match
"Grey area" matches reviewed by hand
Slide 9
Analysis
Cause of Death … defined using ICD-9/10 only underlying COD
AI/AN in analysis = AI/AN (any mention) on death certificate
-
effectivehealthcare.ahrq.gov/sites/default/files/pdf/atypical-antipsychotics-seniors-death_research.pdf
August 01, 2007 - Research Reports
Comparative Safety of Conventional and
Atypical Antipsychotic Medications:
Risk of Death … We also identified the presence of conditions that are
independent predictors of death and were related … Adjusted mortality ratios (MR) comparing the risk of death for initiators of conventional vs.
atypical … Risk of
death in elderly users of conventional vs. atypical
antipsychotic medications. … Sensitivity analysis of the observed association between conventional APM use and death.