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psnet.ahrq.gov/issue/physiology-failure-identifying-risk-factors-mortality-emergency-general-surgery-patients
March 23, 2022 - March 23, 2022
Changes in error patterns in unanticipated trauma deaths during 20 years … : in pursuit of zero preventable deaths. … March 16, 2022
Zero preventable deaths after traumatic injury: an achievable goal.
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psnet.ahrq.gov/issue/patient-safety-community-dementia-services-what-can-we-learn-experiences-caregivers-and
March 05, 2025 - December 14, 2016
Learning from preventable deaths: exploring case record reviewers' … November 12, 2014
Relationship between preventable hospital deaths and other measures … June 17, 2014
Preventable deaths due to problems in care in English acute hospitals:
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psnet.ahrq.gov/issue/presenting-complaint-use-language-disempowers-patients
July 13, 2022 - July 13, 2022
NHS ‘Learning from Deaths’ reports: a qualitative and quantitative document … The quality of 'Learning from Deaths' reporting in quality accounts within the NHS in England 2017-2020 … March 1, 2023
Is anybody 'Learning' from deaths?
-
psnet.ahrq.gov/issue/fractures-fingers-missed-or-misdiagnosed-poorly-positioned-or-poorly-taken-radiographs
September 07, 2022 - March 20, 2019
Changes in error patterns in unanticipated trauma deaths during 20 years … : in pursuit of zero preventable deaths. … March 24, 2021
Zero preventable deaths after traumatic injury: an achievable goal.
-
psnet.ahrq.gov/issue/assessing-clinical-reasoning-targeting-higher-levels-pyramid
June 15, 2022 - The quality of 'Learning from Deaths' reporting in quality accounts within the NHS in England 2017-2020 … March 1, 2023
Is anybody 'Learning' from deaths? … June 1, 2022
NHS ‘Learning from Deaths’ reports: a qualitative and quantitative document
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www.ahrq.gov/patient-safety/quality-measures/21st-century/index.html
June 01, 2018 - percent did not receive life-saving beta-blocker treatment, leading to as many as 18,000 unnecessary deaths … health care delivery lead to missed or delayed diagnoses, higher costs, and unnecessary injuries and deaths … study of New York State hospitals found 1 in 25 patients were injured by the care they received and deaths … Negligence was blamed for 27.6 percent of the injuries and 51.3 percent of the deaths. … Based on this study, researchers estimated that preventable errors in hospital care led to 180,000 deaths
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hcup-us.ahrq.gov/reports/factsandfigures/2009/pdfs/FF_2009_exhibit1_4.pdf
January 01, 2009 - and Other
Facilities
13%
Home Health
Care
10%
Another Short-
term Hospital
2%
In-hospital
Deaths … These included
discharge to another short-term hospital (864,500 stays), in-hospital deaths (757,800 … Long-term Care and Other Facilities
All Stays
Routine
Another Short-term Hospital
In-hospital Deaths … The number of discharges for in-hospital deaths declined by 11 percent between 1997 and 2009.
-
hcup-us.ahrq.gov/reports/factsandfigures/2008/pdfs/section1_5.pdf
January 01, 2008 - and Other
Facilities
13%
Home Health
Care
10%
Another Short-
term Hospital
2%
In-hospital
Deaths … These included
discharge to another short-term hospital (877,700 discharges), in-hospital deaths (811,200 … Long-term Care and Other Facilities
All Discharges
Routine
Another Short-term Hospital
In-hospital Deaths … The number of discharges for in-hospital deaths (down 5 percent) and discharges to another short-term
-
psnet.ahrq.gov/node/74717/psn-pdf
February 02, 2022 - children’s hospital implemented a safe sleep bundle in all departments to reduce sudden unexpected infant
deaths … statewide-nicu-central-line-associated-bloodstream-infection-rates-decline-after-bundles-and
https://psnet.ahrq.gov/issue/association-unexpected-newborn-deaths-changes-obstetric-and-neonatal-process-care
-
psnet.ahrq.gov/node/72568/psn-pdf
January 01, 2021 - alternatives-opioid-education-and-prescription-drug-monitoring-program-
cumulatively-decreased
Reducing opioid-related overdoses and deaths … alternatives-opioid-education-and-prescription-drug-monitoring-program-cumulatively-decreased
https://psnet.ahrq.gov/issue/increases-drug-and-opioid-overdose-deaths-united-states
-
psnet.ahrq.gov/node/74134/psn-pdf
December 01, 2021 - In this study, patient deaths
occurring within 7 days of ED discharge were analyzed to determine if … the deaths were anticipated or
unanticipated and/or due to medical error.
-
psnet.ahrq.gov/issue/childrens-hospital-investigated-five-patient-deaths-deadly-fungal-disease-2009
June 14, 2017 - Newspaper/Magazine Article
Children's Hospital investigated five patient deaths from
-
psnet.ahrq.gov/node/838629/psn-pdf
October 19, 2022 - This
study used data from the Learning from Lives and Deaths (LeDeR) program in the UK to examine the … challenges-monitoring-and-preventing-patient-safety-incidents-people-intellectual
https://psnet.ahrq.gov/issue/leder-learning-lives-and-deaths
-
psnet.ahrq.gov/node/60276/psn-pdf
April 29, 2020 - body-evidence-do-autopsy-findings-impact-medical-malpractice-claim-
outcomes
This study reviewed medical malpractice claims spanning a 10-year period involving deaths … that physicians should not hesitate to advocate for
autopsies to investigate unexpected in-hospital deaths
-
psnet.ahrq.gov/node/47496/psn-pdf
June 15, 2019 - Zealand Audit of Surgical Mortality database
over a 1-year period, researchers fully audited 3422 deaths … surgery might mitigate CDMIs
related to decisions to perform surgery and that retrospectively reviewing deaths
-
psnet.ahrq.gov/node/47834/psn-pdf
February 27, 2019 - Reviewers rated 11 of the 300 sepsis-
associated deaths as definitely or moderately likely preventable … prevalence-underlying-causes-and-preventability-sepsis-associated-mortality-us-acute-care
https://psnet.ahrq.gov/issue/hospital-deaths-patients-sepsis
-
psnet.ahrq.gov/issue/effects-nurse-staffing-and-nurse-education-patient-deaths-hospitals-different-nurse-work
November 21, 2018 - Classic
Effects of nurse staffing and nurse education on patient deaths … Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work … Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work
-
psnet.ahrq.gov/perspective/where-does-risk-adjusted-mortality-fit-safety-measurement-program
March 01, 2015 - The commonly used HSMR is a ratio of the observed number of in-hospital deaths to the number expected … Moreover, when in-hospital deaths are subjected to forensic clinical analysis, studies show that only … Have there been 13,000 needless deaths at 14 NHS trusts? BMJ. 2013;347:f4893. … We point out that the observed minus expected deaths isn't unnecessary deaths and it isn't avoidable … deaths.
-
psnet.ahrq.gov/perspective/conversation-brian-jarman-phd
March 01, 2015 - We point out that the observed minus expected deaths isn't unnecessary deaths and it isn't avoidable … deaths. … It's just the difference between the number of deaths that you get in the hospital and the number that … The commonly used HSMR is a ratio of the observed number of in-hospital deaths to the number expected … Have there been 13,000 needless deaths at 14 NHS trusts? BMJ. 2013;347:f4893.
-
psnet.ahrq.gov/node/60185/psn-pdf
April 01, 2020 - Associations between stopping prescriptions for opioids,
length of opioid treatment, and overdose or suicide
deaths … Associations between stopping prescriptions for opioids, length of
opioid treatment, and overdose or suicide deaths