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psnet.ahrq.gov/innovation/statewide-collaborative-support-vaginal-birth-and-reduce-unnecessary-cesarean-deliveries
July 23, 2024 - Every year since 2006, the CMQCC has gathered a multidisciplinary committee to examine maternal deaths … and identify the causes of these deaths.
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psnet.ahrq.gov/web-mm/sleep-deprivation-leads-medication-error-during-spinal-epidural-anesthesia
January 29, 2021 - enhance cockpit performance of helicopter pilots in operation “Desert Storm” in Iraq, “friendly fire” deaths … US pilots blame drug for friendly fire deaths. The Guardian. January 4, 2003.
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psnet.ahrq.gov/web-mm/dependence-vs-pain
October 30, 2019 - according to the DAWN Mortality Data Report, hydrocodone ranked among the 10 most common drugs related to deaths … Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths
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psnet.ahrq.gov/web-mm/loss-trust-and-missed-diagnosis
October 31, 2023 - Lung cancer is the leading cause of cancer deaths and must be considered in patients with historical … the concern that overprescribing opioids has contributed to the current epidemic of opioid overdose deaths
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psnet.ahrq.gov/web-mm/possible-probable-sure-wrong-premature-closure-and-anchoring-complicated-case
October 02, 2013 - time.( 14 ) Misdiagnoses are estimated to account for approximately 40,000–80,000 preventable hospital deaths … treatment or through the application of incorrect treatments.( 1 ) This estimate accounts neither for deaths
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psnet.ahrq.gov/node/852807/psn-pdf
August 30, 2023 - enhance cockpit performance of helicopter pilots in
operation “Desert Storm” in Iraq, “friendly fire” deaths … US pilots blame drug for friendly fire deaths. The Guardian. January 4, 2003.
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psnet.ahrq.gov/web-mm/spotlight-mistaken-attribution-diagnostic-misstep
July 01, 2011 - Hanging, strangulation, and asphyxiation together accounted for about 60% of attempts and 24 deaths. … The second most common method was cutting with a sharp object, contributing to 23% of attempts but no deaths
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psnet.ahrq.gov/perspective/first-do-no-harm-value-driven-patient-safety-neonatal-intensive-care-unit
October 30, 2019 - For every one of these maternal deaths, there are tens of thousands of cases of avoidable suffering from
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psnet.ahrq.gov/web-mm/fatal-patient-controlled-analgesia-pca-opioid-induced-respiratory-depression
May 26, 2021 - While the first 24-hours after surgery have the highest risk of opioid-induced respiratory depression, deaths
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psnet.ahrq.gov/node/72516/psn-pdf
November 25, 2020 - Premature Closure: Was It Just Syncope?
November 25, 2020
Maurier D, Barnes DK. Premature Closure: Was It Just Syncope? PSNet [internet]. 2020.
https://psnet.ahrq.gov/web-mm/premature-closure-was-it-just-syncope
Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council fo…
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psnet.ahrq.gov/web-mm/lap-burn
March 01, 2018 - , roughly 100 surgical suite fires will occur, causing approximately 20 serious injuries and 1 to 2 deaths
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psnet.ahrq.gov/node/33846/psn-pdf
November 01, 2017 - With literally hundreds of thousands of preventable
deaths and millions of avoidable adverse events
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psnet.ahrq.gov/node/49390/psn-pdf
February 01, 2003 - However, awareness of this hazard has not completely
prevented patient deaths.(1) Although clinicians
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psnet.ahrq.gov/node/49441/psn-pdf
March 01, 2004 - Zinn C. 14,000 preventable deaths in Australian hospitals.
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psnet.ahrq.gov/primer/national-patient-safety-goals
January 16, 2025 - include monitoring, disclosing, and addressing patient safety incidents, patient harms, and avoidable deaths
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psnet.ahrq.gov/issue/rethinking-rapid-response-teams
February 23, 2019 - Commentary
Rethinking rapid response teams.
Citation Text:
Litvak E, Pronovost P. Rethinking rapid response teams. JAMA. 2010;304(12):1375-6. doi:10.1001/jama.2010.1385.
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psnet.ahrq.gov/issue/creating-safe-spaces-organizations-talk-about-safety
March 18, 2019 - Study
Creating safe spaces in organizations to talk about safety.
Citation Text:
Morath J, Leary M. Creating safe spaces in organizations to talk about safety. Nurs Econ. 2004;22(6):344-51, 354.
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psnet.ahrq.gov/issue/teaching-diagnostic-process-model-improve-medical-education
September 20, 2012 - Commentary
Teaching the diagnostic process as a model to improve medical education.
Citation Text:
Sklar DP. Teaching the Diagnostic Process as a Model to Improve Medical Education. Acad Med. 2017;92(1):1-4. doi:10.1097/ACM.0000000000001481.
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psnet.ahrq.gov/issue/emotional-fallout-culture-blame-and-shame
October 28, 2020 - Commentary
The emotional fallout from the culture of blame and shame.
Citation Text:
Ferguson CC. The emotional fallout from the culture of blame and shame. JAMA Pediatr. 2017;171(12):1141. doi:10.1001/jamapediatrics.2017.2691.
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psnet.ahrq.gov/issue/risk-models-improve-safety-dispensing-high-alert-medications-community-pharmacies
December 02, 2020 - Study
Risk models to improve safety of dispensing high-alert medications in community pharmacies.
Citation Text:
Cohen MR, Smetzer JL, Westphal JE, et al. Risk models to improve safety of dispensing high-alert medications in community pharmacies. J Am Pharm Assoc (2003). 2012;52(5):584-6…