Hospital Reporting of Deaths Related to Restraint and Seclusion.

Book/Report

Hospital Reporting of Deaths Related to Restraint and Seclusion.

September 27, 2006

Levinson DR. Washington DC: Office of the Inspector General; September 2006. OEI-09-04-00350

This report presents findings from an investigation into the reporting of and response to restraint and seclusion-related deaths.

Free full text (PDF)

Related Resources From the Same Author(s)

Nursing Home Complaint Investigations.

September 20, 2006

The Food and Drug Administration's National Drug Code Directory.

September 6, 2006

Hospital Incident Reporting Systems Do Not Capture Most Patient Harm.

January 18, 2012

Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries.

November 24, 2010

Medicare's Oversight of Ambulatory Surgery Centers Report.

October 23, 2019

Adverse Events in Long-Term-Care Hospitals: National Incidence Among Medicare Beneficiaries.

January 9, 2019

Adverse Events in Hospitals: Medicare's Responses to Alleged Serious Events.

November 16, 2011

Medicare’s Oversight of Compounded Pharmaceuticals Used in Hospitals.

February 11, 2015

Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries.

July 27, 2016

Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries.

March 19, 2014

Adverse Events in Hospitals: Care Study of Incidence Among Medicare Beneficiaries in Two Selected Counties.

February 18, 2009

Adverse Events in Hospitals: State Reporting Systems.

January 14, 2009

Adverse Events in Hospitals: Overview of Key Issues.

January 14, 2009

Adverse Events in Hospitals: Methods for Identifying Events.

March 17, 2010

Physician-Owned Specialty Hospital's Ability to Manage Medical Emergencies.

January 23, 2008

Hospital Experiences Responding to the COVID-19 Pandemic: Results of a National Pulse Survey March 23-27, 2020.

April 22, 2020

Comprehensive Healthcare Inspection Summary Report: Evaluation of Care Coordination in Veterans Health Administration Facilities, Fiscal Year 2021.

October 12, 2022

Long-Term Trends of Psychotropic Drug Use in Nursing Homes.

February 1, 2023

Adverse Events in Hospitals: A Quarter of Medicare Patients Experienced Harm in October 2018.

May 25, 2022

Medicare Part D Beneficiaries at Serious Risk of Opioid Misuse or Overdose: A Closer Look.

May 20, 2020

Incidence of Adverse Events in Indian Health Service Hospitals.

December 23, 2020

Trends in Nursing Home Deficiencies and Complaints.

October 29, 2008

Few Adverse Events in Hospitals Were Reported to State Adverse Event Reporting Systems.

August 1, 2012

Adverse Events in Hospitals: Public Disclosure of Information About Events.

January 20, 2010

Patient Safety Organizations: Hospital Participation, Value, and Challenges.

October 16, 2019

Opioids in Medicare Part D: Concerns About Extreme Use and Questionable Prescribing.

August 9, 2017

Corporate Responsibility and Health Care Quality: A Resource for Health Care Boards of Directors.

July 18, 2007

Deficiencies in Care, Care Coordination, and Facility Response to a Patient Who Died by Suicide, Memphis VA Medical Center in Tennessee.

September 30, 2020

Adverse Events Toolkit: Medical Record Review Methodology.

July 26, 2023

Adverse Events Toolkit: Clinical Guidance for Identifying Harm

July 19, 2023

Interim Report: Review of VHA's Patient Wait Times, Scheduling Practices, and Alleged Patient Deaths at the Phoenix Health Care System.

June 4, 2014

Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System.

September 10, 2014

Deficiencies in Emergent and Outpatient Care of a Patient with Alcohol Use Disorder at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana.

April 19, 2023

Inadequate Outpatient Mental Health Triage and Care of a Patient at the Chico Community-Based Outpatient Clinic in California.

March 1, 2023

The New Electronic Health Record’s Unknown Queue Caused Multiple Events of Patient Harm.

July 27, 2022

Comprehensive Healthcare Inspection Summary Report: Evaluation of Mental Health in Veterans Health Administration Facilities, Fiscal Year 2020.

March 16, 2022

Quality of Care Concerns and the Facility Response Following a Medical Emergency at the VA Southern Nevada Health Care System in Las Vegas.

July 26, 2023

Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center in Virginia.

July 13, 2022

Inadequate Emergency Department Care and Physician Misconduct at the Washington DC VA Medical Center.

August 12, 2020

Healthcare Inspection: Evaluation of the Veterans Health Administration's National Consult Delay Review and Associated Fact Sheet.

January 14, 2015

Quality of Care in Cranial Implant Surgeries at James A. Haley VA Medical Center, Tampa, Florida.

April 26, 2006

Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical Center in Spokane, WA.

March 30, 2022

Evaluation of Registered Nurse Competency Processes in Veterans Health Administration Facilities.

June 13, 2012

Unexpected Death of a Patient During Treatment With Multiple Medications, Tomah VA Medical Center, Tomah, Wisconsin.

September 16, 2015

Evaluation of Quality, Safety and Value in Veterans Health Administration Facilities, Fiscal 2021.

November 16, 2022

Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, FY 2020.

September 15, 2021

Deficiencies in the Veterans Crisis Line Response to a Veteran Caller Who Died.

December 16, 2020

Deficiencies in Inpatient Mental Health Care Coordination and Processes Prior to a Patient's Death by Suicide, Harry S. Truman Memorial Veterans' Hospital in Columbia, Missouri.

February 10, 2021

Critical Deficiencies at the Washington DC VA Medical Center.

March 21, 2018

Healthcare Inspection—Emergency Department Patient Deaths: Memphis VAMC, Memphis, Tennessee.

November 13, 2013

Patient Suicide on a Locked Mental Health Unit at the West Palm Beach VA Medical Center, Florida.

September 4, 2019

Failures in Care Coordination and Reviewing a Patient's Death at the VA Salt Lake City Healthcare System in Utah.

August 25, 2021

Deficiencies in Emergency Preparedness for Veterans Health Administration Telemental Health Care at VA Clinic Locations Prior to the Pandemic.

July 14, 2021

Care and Oversight Deficiencies Related to Multiple Homicides at the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia.

May 26, 2021

Deficiencies in Emergency Department Care for a Patient Who Died by Suicide at the John Cochran Division of the VA St. Louis Health Care System in Missouri.

August 2, 2023

Deficient Care of a Patient Who Died by Suicide and Facility Leaders' Response at the Charlie Norwood VA Medical Center in Augusta, Georgia.

July 5, 2023

Deficiencies in Care Coordination and Facility Response to a Patient Suicide at the Minneapolis VA Health Care System, Minnesota.

January 29, 2020

Assessment of DoD Wounded Warrior Matters: Managing Risks of Multiple Medications.

March 5, 2014

Safety Assurance Factors for EHR Resilience: SAFER Guides.

January 29, 2014

Addressing Health Worker Burnout.

June 8, 2022

Department of Defense Health Care Quality.

January 10, 2007

Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health IT and EHRs.

December 12, 2018

Health IT Patient Safety Action and Surveillance Plan.

July 17, 2013

Health IT Safety Center Roadmap.

July 29, 2015

Solicitation for written comments on draft National Action Plan for Adverse Drug Event Prevention.

September 18, 2013

Recent Evidence That Health IT Improves Patient Safety: Issue Brief.

May 13, 2015

Cybersecurity is Patient Safety: Policy Options in the Health Care Sector.

December 14, 2022

Medication Management: Detailed Use Case.

July 4, 2007

National Action Plan for Adverse Drug Event Prevention.

September 24, 2014

FDASIA Health IT Report: Proposed Strategy and Recommendations for a Risk-Based Framework.

April 30, 2014

How to Identify and Address Unsafe Conditions Associated With Health IT.

December 18, 2013

Pathology Oversight Failures at the Veterans Health Care System of the Ozarks in Fayetteville, Arkansas VA.

June 16, 2021

Promoting Patient Safety Through Effective Health Information Technology Risk Management.

July 23, 2014

Placing Diagnosis Errors on the Policy Agenda.

May 21, 2014

VA Patient Safety Program: A Cultural Perspective at Four Medical Facilities.

January 4, 2006

Clinical Lab Quality: CMS and Survey Organization Oversight Should Be Strengthened.

July 12, 2006

VA Health Care: Selected Credentialing Requirements at Seven Medical Facilities Met, but an Aspect of Privileging Process Needs Improvement.

July 5, 2006

VA Health Care: Steps Taken to Improve Practitioner Screening, but Facility Compliance with Screening Requirements is Poor.

July 5, 2006

Goals and Priorities for Health Care Organizations to Improve Safety Using Health IT. Revised Report.

June 29, 2016

Patient Options for Safe and Effective Disposal of Unused Opioids.

September 25, 2019

Health-Care-Associated Infections in Hospitals: An Overview of State Reporting Programs and Individual Hospital Initiatives to Reduce Certain Infections.

October 15, 2008

COVID-19 in Nursing Homes: CMS Needs to Continue to Strengthen Oversight of Infection Prevention and Control.

October 12, 2022

Artificial Intelligence in Health Care: Benefits and Challenges of Machine Learning Technologies for Medical Diagnostics.

October 26, 2022

Standardizing a Patient Safety Taxonomy.

February 22, 2006

2006 Update on Consumers' Views of Patient Safety and Quality Information.

October 4, 2006

Patient Safety as an Exercise in Behavioral Change.

October 24, 2012

Improving Diagnostic Quality and Safety Final Report.

September 27, 2017

Nursing Homes: Despite Increased Oversight, Challenges Remain in Ensuring High-Quality Care and Resident Safety.

January 31, 2006

Defense Health Agency Processes for Responding to Provider Quality and Safety Concerns.

December 23, 2020

Greater Focus on Credentialing Needed to Prevent Disqualified Providers From Delivering Patient Care.

March 13, 2019

Trends in Pregnancy-Related Deaths and Federal Efforts to Reduce Them.

April 29, 2020

Approaches and Challenges to Electronically Matching Patients' Records Across Providers.

March 6, 2019

Actions Needed to Address Employee Misconduct Process and Ensure Accountability.

August 15, 2018

Progress Made Towards Improving Opioid Safety, But Further Efforts to Assess Progress and Reduce Risk Are Needed.

July 11, 2018

Defense Health Agency Should Improve Tracking of Serious Adverse Medical Events and Monitoring of Required Follow-up.

May 16, 2018

Improved Policies and Oversight Needed for Reviewing and Reporting Providers for Quality and Safety Concerns.

December 6, 2017

Prescription Opioids: Medicare Needs to Expand Oversight Efforts to Reduce the Risk of Harm.

November 22, 2017

Veterans Health Care: Veterans Health Administration Processes for Responding to Reported Adverse Events.

September 5, 2012

Patient Safety: Hospitals Face Challenges Implementing Evidence-Based Practices.

March 9, 2016

Artificial Intelligence in Health Care: Benefits and Challenges of Technologies to Augment Patient Care.

December 9, 2020

Related Resources

Quality of Care Concerns and the Facility Response Following a Medical Emergency at the VA Southern Nevada Health Care System in Las Vegas.

July 26, 2023

National statutory reporting: not even ticking the boxes? The quality of 'Learning from Deaths' reporting in quality accounts within the NHS in England 2017-2020.

March 1, 2023

'Reading the Signals' : Maternity and Neonatal Services in East Kent – the Report of the Independent Investigation.

November 16, 2022

National Healthcare Quality and Disparities Reports.

November 7, 2022

The National Healthcare System Action Alliance to Advance Patient Safety.

November 14, 2022 - November 14, 2022

Concordance of hospital ranks and category ratings using the current technical specification of US Hospital Star Ratings and reasonable alternative specifications.

August 31, 2022

Risk reduction strategy to decrease incidence of retained surgical items.

August 31, 2022

Examining the Status of VA’s Electronic Health Record Modernization Program.

August 10, 2022

Adverse Health Events in Minnesota: Annual Reports.

August 9, 2022

Independent Neurology Inquiry.

July 20, 2022

The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff.

April 20, 2022

The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity.

May 19, 2021

Documenting a Day of Discussion: Ahead of the Crest of the Wave Creating the National Agenda for Systemic Change for Enhanced Clinician Well-Being.

April 14, 2021

Medicare cuts payment to 774 hospitals over patient complications.

March 3, 2021

Best Practices in Developing Proprietary Names for Human Nonprescription Drug Products.

January 13, 2021

Ockenden Report. Emerging Fndings and Recommendations from the Independent Review of Maternity Services at the Shrewsbury and Telford Hospital NHS Trust.

January 13, 2021

Private patient rooms and hospital-acquired methicillin-resistant Staphylococcus aureus: hospital-level analysis of administrative data from the United States.

August 5, 2020

First Do No Harm. The Report of the Independent Medicines and Medical Devices Safety Review.

July 22, 2020

Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior to COVID-19 Pandemic.

May 27, 2020

Medicare Part D Beneficiaries at Serious Risk of Opioid Misuse or Overdose: A Closer Look.

May 20, 2020

Trends in Pregnancy-Related Deaths and Federal Efforts to Reduce Them.

April 29, 2020

Hospital Experiences Responding to the COVID-19 Pandemic: Results of a National Pulse Survey March 23-27, 2020.

April 22, 2020

She hoped to shine a light on maternal mortality among Native Americans. Instead, she became a statistic of it.

February 26, 2020

An Organisation Losing its Memory? Patient Safety Alerts: Implementation, Monitoring and Regulation in England

February 19, 2020

Investigation into Detection of Retained Vaginal Swabs and Tampons Following Childbirth.

January 22, 2020

Adverse Events in Long-Term-Care Hospitals: National Incidence Among Medicare Beneficiaries.

January 9, 2019

Improved Policies and Oversight Needed for Reviewing and Reporting Providers for Quality and Safety Concerns.

December 6, 2017

Learning From Mistakes.

August 31, 2016

Adverse Events in Rehabilitation Hospitals: National Incidence Among Medicare Beneficiaries.

July 27, 2016

Preventable Tragedies: Superbugs and How Ineffective Monitoring of Medical Device Safety Fails Patients.

February 3, 2016

See More About The Topic

Health Care Executives and Administrators

Hospital Reporting of Deaths Related to Restraint and Seclusion.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Hospital Reporting of Deaths Related to Restraint and Seclusion.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site