Review Patterns of unexpected in-hospital deaths: a root cause analysis. Citation Text: Lynn LA, Curry P. Patterns of unexpected in-hospital deaths: a root cause analysis. Patient Saf Surg. 2011;5(1):3. doi:10.1186/1754-9493-5-3. Copy Citation Format: Google ScholarDOIPubMedBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL March 16, 2011 Lynn LA, Curry P. Patient Saf Surg. 2011;5(1):3. View more articles from the same authors. This literature review concluded that the history and scientific basis for threshold alarms are quite arbitrary, and new methods and technologies are needed to identify actual patterns of evolving death. PubMed citation Available at Free full text Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Cite Citation Citation Text: Lynn LA, Curry P. Patterns of unexpected in-hospital deaths: a root cause analysis. Patient Saf Surg. 2011;5(1):3. doi:10.1186/1754-9493-5-3. Copy Citation Format: Google ScholarDOIPubMedBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Related Resources From the Same Author(s) Artificial intelligence systems for complex decision-making in acute care medicine: a review. March 13, 2019 A new tool to give hospitalists feedback to improve interprofessional teamwork and advance patient care. November 28, 2012 When does quality improvement count as research? Human subject protection and theories of knowledge. March 6, 2005 Transforming the health care environment collaborative. April 9, 2014 Simulation exercises as a patient safety strategy: a systematic review. March 20, 2013 How guiding coalitions promote positive culture change in hospitals: a longitudinal mixed methods interventional study. November 15, 2017 Getting by: underuse of interpreters by resident physicians. 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September 25, 2013 View More See More About The Topic General Hospitals Health Care Executives and Administrators Safety Scientists Engineers Critical Care View More
Artificial intelligence systems for complex decision-making in acute care medicine: a review. March 13, 2019
A new tool to give hospitalists feedback to improve interprofessional teamwork and advance patient care. November 28, 2012
When does quality improvement count as research? Human subject protection and theories of knowledge. March 6, 2005
How guiding coalitions promote positive culture change in hospitals: a longitudinal mixed methods interventional study. November 15, 2017
"Out of sight, out of mind": housestaff perceptions of quality-limiting factors in discharge care at teaching hospitals. July 18, 2012
"Learning by Doing"—resident perspectives on developing competency in high-quality discharge care. June 20, 2012
Design and trial of a new ambulance-to-emergency department handover protocol: 'IMIST-AMBO.' August 1, 2012
Better medical office safety culture is not associated with better scores on quality measures. January 11, 2012
Influencing organisational culture to improve hospital performance in care of patients with acute myocardial infarction: a mixed-methods intervention study. November 22, 2017
Achieving rapid door-to-balloon times: how top hospitals improve complex clinical systems. March 8, 2006
Racial disparities in the frequency of patient safety events: results from the National Medicare Patient Safety Monitoring System. June 1, 2011
Contemporary evidence about hospital strategies for reducing 30-day readmissions: a national study. November 7, 2012
Patient safety perceptions in pediatric out-of-hospital emergency care: Children's Safety Initiative. September 9, 2015
Consensus statement on effective communication of urgent diagnoses and significant, unexpected diagnoses in surgical pathology and cytopathology from the College of American Pathologists and Association of Directors of Anatomic and Surgical Pathology. October 26, 2011
Assessment of incorrect surgical procedures within and outside the operating room. A follow-up study from US Veterans Health Administration medical centers. December 5, 2018
Regulatory and policy barriers to effective clinical data exchange: lessons learned from MedsInfo-ED. October 5, 2005
A review of educational philosophies as applied to radiation safety training at medical institutions. May 24, 2006
Community-acquired and hospital-acquired medication harm among older inpatients and impact of a state-wide medication management intervention. November 14, 2018
Obstetrician-gynecologists' opinions about patient safety: costs and liability remain problems; are mandated reports a solution? February 4, 2009
Establishing a multi-institutional quality and patient safety consortium: collaboration across affiliates in a community-based medical school. January 20, 2021
Changing hospital organisational culture for improved patient outcomes: developing and implementing the Leadership Saves Lives intervention. August 12, 2020
The relationship of self-report of quality to practice size and health information technology. October 10, 2012
Instituting a culture of professionalism: the establishment of a Center for Professionalism and Peer Support. April 16, 2014
Redesigning a morbidity and mortality program in a university-affiliated pediatric anesthesia department. February 24, 2010
"Sorry" is never enough: how state apology laws fail to reduce medical malpractice liability risk. April 24, 2019
Recognizing and responding to the "toxic" work environment: worker safety, patient safety, and abuse/neglect in nursing homes. September 20, 2017
The efficacy of medical team training: improved team performance and decreased operating room delays: a detailed analysis of 4863 cases. September 15, 2010
Self-Reported Learning (SRL), a voluntary incident reporting system experience within a large health care organization. May 12, 2021
Relation between malpractice claims and adverse events due to negligence. Results of the Harvard Medical Practice Study III. March 27, 2005
How does workplace violence-reporting culture affect workplace violence, nurse burnout, and patient safety? December 7, 2022
Higher rates of misdiagnosis in pediatric patients versus adults hospitalized with imported malaria. November 26, 2014
The impact of surgical count technology on retained surgical items rates in the Veterans Health Administration. April 22, 2020
Delayed access to care and late presentations in children during the COVID-19 pandemic: a snapshot survey of 4075 paediatricians in the UK and Ireland. July 29, 2020
Trends in the prevalence of intraoperative adverse events at two academic hospitals after implementation of a mandatory reporting system. April 25, 2018
The relationship of the emotional climate of work and threat to patient outcome in a high-volume thoracic surgery operating room team. March 16, 2011
Can first-year medical students acquire quality improvement knowledge prior to substantial clinical exposure? A mixed-methods evaluation of a pre-clerkship curriculum that uses education as the context for learning. May 2, 2018
Effect of social influences on pharmacists' intention to report adverse drug events. October 17, 2012
Team debriefing in the COVID-19 pandemic: a qualitative study of a hospital-wide clinical event debriefing program and a novel qualitative model to analyze debriefing content. November 16, 2022
Evidence of respiratory infection transmission within physician offices could inform outpatient infection control. September 1, 2021
Rates of new or missed colorectal cancers after colonoscopy and their risk factors: a population-based analysis. March 28, 2007
The e-Autopsy/e-Biopsy: a systematic chart review to increase safety and diagnostic accuracy. October 26, 2022
Improving oversight of the graduate medical education enterprise: one institution's strategies and tools. May 10, 2006
Patient safety culture transformation in a children's hospital: an interprofessional approach. April 30, 2014
Improving patient safety in clinical oncology: applying lessons from Normal Accident Theory. October 21, 2015
Analysis of consistency in emergency department physician variation in propensity for admission across patient sociodemographic groups. October 13, 2021
Predictors of treatment error for children with uncomplicated malaria seen as outpatients in Blantyre district, Malawi. September 13, 2006
Disorganized care: the findings of an iterative, in-depth analysis of surgical morbidity and mortality. November 21, 2012
The importance of failing forward. All of us will fail and make mistakes, but how can they benefit us and our organizations? June 27, 2012
Reliability, uncertainty and the management of error: new perspectives in the COVID-19 era. March 9, 2022
From good intentions to successful implementation: the case of patient safety in Canada. February 28, 2007
Using drug knowledgebase information to distinguish between look-alike-sound-alike drugs. June 27, 2018
Relationship between physician burnout and the quality and cost of care for Medicare beneficiaries is complex. April 20, 2022
Are parents who feel the need to watch over their children's care better patient safety partners? December 6, 2017
Resident participation does not affect surgical outcomes, despite introduction of new techniques. September 22, 2010
Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. March 27, 2005
Results of an effort to integrate quality and safety into medical and nursing school curricula and foster joint learning. December 19, 2012
Implementing computerized provider order entry with an existing clinical information system. August 23, 2006
Nonoperating room anaesthesia: safety, monitoring, cognitive aids and severe acute respiratory syndrome coronavirus 2. August 12, 2020
Medication safety in emergency medical services: approaching an evidence-based method of verification to reduce errors. April 3, 2019
Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are they preventable? October 4, 2006
Patient Safety Innovations Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis May 31, 2023
Value of improving patient safety: health economic considerations for rapid response systems-a rapid review of the literature and expert round table. May 3, 2023
Interview In Conversation with Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring April 26, 2023
Perspective Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units April 26, 2023
Why do healthcare professionals fail to escalate as per the early warning system (EWS) protocol? A qualitative evidence synthesis of the barriers and facilitators of escalation. February 17, 2021
The effect of blue-enriched lighting on medical error rate in a university hospital ICU. January 27, 2021
Data-driven implementation of alarm reduction interventions in a cardiovascular surgical ICU. February 8, 2017
Patient safety implications of electronic alerts and alarms of maternal–fetal status during labor. August 31, 2016
Changes in default alarm settings and standard in-service are insufficient to improve alarm fatigue in an intensive care unit: a pilot project. February 17, 2016
Stop the noise: a quality improvement project to decrease electrocardiographic nuisance alarms. August 19, 2015
Association between exposure to nonactionable physiologic monitor alarms and response time in a children's hospital. April 29, 2015
Alarm system management: evidence-based guidance encouraging direct measurement of informativeness to improve alarm response. April 1, 2015
Insights into the problem of alarm fatigue with physiologic monitor devices: a comprehensive observational study of consecutive intensive care unit patients. November 12, 2014
Evaluating implementation of a rapid response team: considering alternative outcome measures. May 7, 2014
Use of paediatric early warning systems in Great Britain: has there been a change of practice in the last 7 years? February 26, 2014
Impact of rapid response system implementation on critical deterioration events in children. November 13, 2013
Using crew resource management and a 'read-and-do checklist' to reduce failure-to-rescue events on a step-down unit. November 6, 2013
Utility and assessment of non-technical skills for rapid response systems and medical emergency teams. October 16, 2013