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psnet.ahrq.gov/issue/identifying-patient-safety-problems-associated-information-technology-general-practice
December 21, 2017 - February 8, 2023
Hemodialysis bleeding events and deaths: an 18-year retrospective analysis
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psnet.ahrq.gov/issue/explaining-organisational-responses-board-level-quality-improvement-intervention-findings
November 21, 2017 - October 5, 2022
Zero: Eliminating Unnecessary Deaths in a Post-pandemic NHS.
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psnet.ahrq.gov/issue/medication-opioid-use-disorder-after-nonfatal-opioid-overdose-and-association-mortality
October 03, 2018 - March 24, 2019
Prevention of prescription opioid misuse and projected overdose deaths
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psnet.ahrq.gov/issue/quasi-experimental-evaluation-effectiveness-large-scale-readmission-reduction-program
January 07, 2015 - View More
Related Resources
Surveying care teams after in-hospital deaths
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psnet.ahrq.gov/issue/cluster-randomized-trial-two-implementation-strategies-deliver-audit-and-feedback-equipped
September 01, 2018 - Consistency between coded poison center data and fatality abstract narratives for therapeutic error deaths
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psnet.ahrq.gov/issue/adverse-drug-events-among-hospitalized-medicare-patients-epidemiology-and-national-estimates
April 05, 2016 - November 30, 2023
Is anybody 'Learning' from deaths?
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psnet.ahrq.gov/issue/identification-doctors-risk-recurrent-complaints-national-study-healthcare-complaints
September 07, 2011 - error in hospitals using incident-reporting systems, patient complaints and chart review of inpatient deaths
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psnet.ahrq.gov/issue/integrating-incident-data-five-reporting-systems-assess-patient-safety-making-sense-elephant
November 25, 2009 - error in hospitals using incident-reporting systems, patient complaints and chart review of inpatient deaths
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psnet.ahrq.gov/issue/incidence-and-types-preventable-adverse-events-elderly-patients-population-based-review
June 23, 2015 - May 18, 2022
Accidental deaths, saved lives, and improved quality.
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psnet.ahrq.gov/issue/cost-effectiveness-computerized-provider-order-entry-system-improving-medication-safety
August 09, 2017 - Comparison of military and civilian methods for determining potentially preventable deaths
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psnet.ahrq.gov/perspective/conversation-withpatrick-tighe-about-artificial-intelligence
March 27, 2024 - 28, 2022
Classifying errors in preventable and potentially preventable trauma deaths
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psnet.ahrq.gov/web-mm/real-heartache
October 01, 2018 - A Real Heartache
Citation Text:
Polevoi SK. A Real Heartache. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2012.
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psnet.ahrq.gov/web-mm/liver-failure-after-chemotherapy-did-we-forget-something
May 01, 2019 - Liver Failure After Chemotherapy: Did We Forget Something?
Citation Text:
Lubel J. Liver Failure After Chemotherapy: Did We Forget Something?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/web-mm/dilute-or-not-dilute-drug-errors-and-consequences-operating-room
July 28, 2021 - To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room
Citation Text:
Aldwinckle R, Florendo E. To Dilute or Not Dilute: Drug Errors and Consequences in the Operating Room. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…
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psnet.ahrq.gov/node/73953/psn-pdf
October 27, 2021 - Deprescribing as a Patient Safety Strategy
October 27, 2021
Takhar S, Nelson N. Deprescribing as a Patient Safety Strategy. PSNet [internet]. 2021.
https://psnet.ahrq.gov/primer/deprescribing-patient-safety-strategy
Background
Polypharmacy is defined as the act of taking five or more medications on a regular basis…
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psnet.ahrq.gov/web-mm/after-visit-confusion
August 21, 2007 - After-Visit Confusion
Citation Text:
Ventres W. After-Visit Confusion. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2014.
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psnet.ahrq.gov/web-mm/poor-prognosis
March 15, 2016 - SPOTLIGHT CASE
Poor Prognosis
Citation Text:
Lamont EB. Poor Prognosis. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2004.
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psnet.ahrq.gov/web-mm/crossed-coverage
September 01, 2015 - Crossed Coverage
Citation Text:
Kayser SR. Crossed Coverage. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2007.
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psnet.ahrq.gov/web-mm/case-patient-flow-management
February 23, 2019 - The Case for Patient Flow Management
Citation Text:
Litvak E, Bernheim SA. The Case for Patient Flow Management. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2011.
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psnet.ahrq.gov/web-mm/dying-hospital-advanced-dementia
November 01, 2016 - Describe one simple strategy to ensure primary care providers are aware of in-hospital deaths.