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Examining causes and prevention strategies of adverse events in deceased hospital patients: a retrospective patient record review study in the Netherlands.
Smits M, Langelaan M, de Groot J, et al. Examining causes and prevention strategies of adverse events in deceased hospital patients: a retrospective patient record review study in the Netherlands. J Patient Saf. 2021;17(4):282-289. doi: 10.1097/pts.0000000000000586.
This study used trained reviewers to examine root causes of adverse events in 571 deceased hospital patients in the Netherlands. Preventable adverse events were commonly caused by technical, organizational, and human causes; technical causes also commonly contributed to preventable deaths from adverse events. The authors discuss strategies to reduce adverse events, including improving communication and information structures, evaluating safety behaviors, and continuous monitoring of patient safety and quality data.
