AHRQ Patient Safety Network

Saving lives by studying deaths: using standardized mortality reviews to improve inpatient safety.

Lau H, Litman KC. Jt Comm J Qual Patient Saf. 2011;37:400-408.

This study reports on Kaiser Permanente's use of systems analysis approaches to review all cases of inpatient mortality, with the goal of identifying preventable harm.

PubMed citation

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Resource Type

Study

Setting of Care

Hospitals

Target Audience

Health Care Providers

Quality and Safety Professionals

Clinical Area

General Internal Medicine

Hospital Medicine

Safety Target

Discontinuities, Gaps, and Hand-Off Problems

Medication Errors/Preventable Adverse Drug Events

Nosocomial Infections

Pressure Ulcers

Surgical Complications

Error Types

Epidemiology of Errors and Adverse Events

Approach to Improving Safety

Audit and Feedback

Origin/Sponsor

United States of America