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www.uspreventiveservicestaskforce.org/home/getfilebytoken/2GDCmTe7akyrAHsTMbfz72
May 06, 2022 - Senger, MPH
C ardiovascular disease (CVD) is the leading cause of
death in the US.1 Aspirin has long … harms (KQ2) were total major
bleeding (bleeding requiring transfusion or hospitalization or
leading to death … Effect of daily aspirin on
long-term risk of death due to cancer: analysis of
individual patient data … Short-term effects of daily aspirin on cancer
incidence, mortality, and non-vascular death:
analysis
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/MeasureDx-guide.pdf
July 01, 2022 - Safety Data Already Collected
by the Organization
Strategy A
Case Example
Learning From Every
Death … Learning from every death. … harm
� Category H- An error occurred that required intervention necessary to sustain
life
Error, Death … � Category I- An error occurred that may have contributed to or resulted in the
patient’s death … treatment
Very Serious Harm/danger of permanent damage
Serious Permanent Damage
Immediate and Inevitable Death
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www.ahrq.gov/sites/default/files/publications2/files/MeasureDx-guide.pdf
July 01, 2022 - Safety Data Already Collected
by the Organization
Strategy A
Case Example
Learning From Every
Death … Learning from every death. … harm
� Category H- An error occurred that required intervention necessary to sustain
life
Error, Death … � Category I- An error occurred that may have contributed to or resulted in the
patient’s death … treatment
Very Serious Harm/danger of permanent damage
Serious Permanent Damage
Immediate and Inevitable Death
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psnet.ahrq.gov/node/37030/psn-pdf
June 23, 2017 - A series of anesthesia-related maternal deaths in
Michigan, 1985-2003.
June 23, 2017
Mhyre JM, Riesner MN, Polley LS, et al. A series of anesthesia-related maternal deaths in Michigan, 1985-
2003. Anesthesiology. 2007;106(6):1096-1104.
https://psnet.ahrq.gov/issue/series-anesthesia-related-maternal-deaths-michigan…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/pneumonia-antibiotic-treatment_executive.pdf
November 01, 2014 - lengths of
stay and costs of care; in one report from Asian countries,
they were associated with death … ventilation
1 prospective
cohort (n=638)
High NA Direct Imprecise Insufficient
Mortality
(composite
of death … response or days
on a ventilator—or preferably, patient-centered health
outcomes, especially disease or death
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/mat-retention-strategies-rapid-review-1.pdf
August 01, 2020 - Mortality after prison release: opioid
overdose and other causes of death, risk
factors, and time trends … dispensed
medication
between
randomization
and end of
study period
(March 31,
2013) or date
of death
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effectivehealthcare.ahrq.gov/products/lung-cancer-nonsurgical-therapies/research-protocol
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psnet.ahrq.gov/sites/default/files/2022-02/final_cme_reviewed_spotlight_loss_of_trust_and_a_missed_diagnosis_02.14.20221_-_clean_-_revised.pdf
January 01, 2022 - Microsoft PowerPoint - FINAL CME Reviewed Spotlight_Loss of Trust and a Missed Diagnosis_02.14.20221 - clean - REVISED.pptx
Spotlight
A Loss of Trust and a Missed Diagnosis
Source and Credits
• This presentation is based on the February 2022 AHRQ WebM&M
Spotlight Case
o See the full article at https://psnet.ahrq.…
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effectivehealthcare.ahrq.gov/sites/default/files/pdf/renal-cancer_clinician.pdf
July 01, 2017 - Management of Renal Masses and Localized Renal Cell Carcinoma: Current State of the Evidence
Management of Renal Masses and Localized Renal Cell
Carcinoma: Current State of the Evidence
Focus of This Summary
This is a summary of a systematic review that evaluated the recent evidence regarding the benefits and adve…
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psnet.ahrq.gov/node/50841/psn-pdf
January 29, 2020 - acute
hemolytic reaction, and 1 in 1.8 million units of transfused red blood cell units results in death
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psnet.ahrq.gov/node/36917/psn-pdf
September 01, 2011 - Analysis of deaths related to anesthesia in the period
1996-2004 from closed claims registered by the Danish
Patient Insurance Association.
September 1, 2011
Hove LD, Steinmetz J, Christoffersen JK, et al. Analysis of deaths related to anesthesia in the period 1996-
2004 from closed claims registered by the Danish…
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psnet.ahrq.gov/node/40404/psn-pdf
February 10, 2015 - The quality 'journey' at Ascension Health: how we've
prevented at least 1,500 avoidable deaths a year—and aim
to do even better.
February 10, 2015
Pryor D, Hendrich A, Henkel RJ, et al. The quality 'journey' at Ascension Health: how we've prevented at
least 1,500 avoidable deaths a year--and aim to do even better.…
-
psnet.ahrq.gov/node/43602/psn-pdf
October 15, 2014 - Classifying errors in preventable and potentially
preventable trauma deaths: a 9-year review using the
Joint Commission's standardized methodology.
October 15, 2014
Vioque SM, Kim PK, McMaster J, et al. Classifying errors in preventable and potentially preventable trauma
deaths: a 9-year review using the Joint Com…
-
psnet.ahrq.gov/node/35023/psn-pdf
March 04, 2011 - Building a framework for trust: critical event analysis of
deaths in surgical care.
March 4, 2011
Thompson A, Stonebridge PA. Building a framework for trust: critical event analysis of deaths in surgical
care. BMJ. 2005;330(7500):1139-42.
https://psnet.ahrq.gov/issue/building-framework-trust-critical-event-analysi…
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psnet.ahrq.gov/node/45301/psn-pdf
April 22, 2017 - Reviewing deaths in British and US hospitals: a study of
two scales for assessing preventability.
April 22, 2017
Manaseki-Holland S, Lilford RJ, Bishop JRB, et al. Reviewing deaths in British and US hospitals: a study of
two scales for assessing preventability. BMJ Qual Saf. 2017;26(5):408-416. doi:10.1136/bmjqs-20…
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psnet.ahrq.gov/node/44466/psn-pdf
September 16, 2015 - Is researching adverse events in hospital deaths a good
way to describe patient safety in hospitals: a
retrospective patient record review study.
September 16, 2015
Baines RJ, Langelaan M, de Bruijne M, et al. Is researching adverse events in hospital deaths a good way
to describe patient safety in hospitals: a re…
-
psnet.ahrq.gov/node/43667/psn-pdf
November 12, 2014 - Learning from preventable deaths: exploring case record
reviewers' narratives using change analysis.
November 12, 2014
Hogan H, Healey F, Neale G, et al. Learning from preventable deaths: exploring case record reviewers'
narratives using change analysis. J R Soc Med. 2014;107(9):365-75. doi:10.1177/0141076814532394…
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psnet.ahrq.gov/node/45898/psn-pdf
August 16, 2017 - Estimating hospital-related deaths due to medical error: a
perspective from patient advocates.
August 16, 2017
Kavanagh KT, Saman DM, Bartel R, et al. Estimating Hospital-Related Deaths Due to Medical Error: A
Perspective From Patient Advocates. J Patient Saf. 2017;13(1):1-5. doi:10.1097/PTS.0000000000000364.
http…
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psnet.ahrq.gov/node/47054/psn-pdf
July 19, 2018 - A target to achieve zero preventable trauma deaths
through quality improvement.
July 19, 2018
Hashmi ZG, Haut ER, Efron DT, et al. A Target to Achieve Zero Preventable Trauma Deaths Through
Quality Improvement. JAMA Surg. 2018;153(7):686-689. doi:10.1001/jamasurg.2018.0159.
https://psnet.ahrq.gov/issue/target-achi…
-
psnet.ahrq.gov/node/36037/psn-pdf
June 25, 2009 - Preventable deaths in patients admitted from emergency
department.
June 25, 2009
Lu T-C, Tsai C-L, Lee C-C, et al. Preventable deaths in patients admitted from emergency department.
Emerg Med J. 2006;23(6):452-5.
https://psnet.ahrq.gov/issue/preventable-deaths-patients-admitted-emergency-department
The authors re…