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: DOIGoogle ScholarPubMedBibTeXEndNote 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: DOIGoogle ScholarPubMedBibTeXEndNote 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 Design and trial of a new ambulance-to-emergency department handover protocol: 'IMIST-AMBO.' August 1, 2012 Physicians and electronic health records: a statewide survey. March 21, 2007 Relation between malpractice claims and adverse events due to negligence. Results of the Harvard Medical Practice Study III. March 27, 2005 Achieving rapid door-to-balloon times: how top hospitals improve complex clinical systems. March 8, 2006 Influencing organisational culture to improve hospital performance in care of patients with acute myocardial infarction: a mixed-methods intervention study. 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Artificial intelligence systems for complex decision-making in acute care medicine: a review. March 13, 2019
Design and trial of a new ambulance-to-emergency department handover protocol: 'IMIST-AMBO.' August 1, 2012
Relation between malpractice claims and adverse events due to negligence. Results of the Harvard Medical Practice Study III. March 27, 2005
Achieving rapid door-to-balloon times: how top hospitals improve complex clinical systems. March 8, 2006
Influencing organisational culture to improve hospital performance in care of patients with acute myocardial infarction: a mixed-methods intervention study. November 22, 2017
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
Establishing a multi-institutional quality and patient safety consortium: collaboration across affiliates in a community-based medical school. January 20, 2021
Obstetrician-gynecologists' opinions about patient safety: costs and liability remain problems; are mandated reports a solution? February 4, 2009
Changing hospital organisational culture for improved patient outcomes: developing and implementing the Leadership Saves Lives intervention. August 12, 2020
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
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
Better medical office safety culture is not associated with better scores on quality measures. January 11, 2012
Racial disparities in the frequency of patient safety events: results from the National Medicare Patient Safety Monitoring System. June 1, 2011
An initiative to reduce insulin-related adverse drug events in a children's hospital. February 16, 2022
A multi-method exploratory evaluation of a service designed to improve medication safety for patients with monitored dosage systems following hospital discharge. October 25, 2023
Assessment of physician sleep and wellness, burnout, and clinically significant medical errors. January 13, 2021
Analysis of consistency in emergency department physician variation in propensity for admission across patient sociodemographic groups. October 13, 2021
Alterations in Spanish language interpretation during pediatric critical care family meetings. December 6, 2017
Development and pilot testing of guidelines to monitor high-risk medications in the ambulatory setting. August 11, 2010
Regulatory and policy barriers to effective clinical data exchange: lessons learned from MedsInfo-ED. October 5, 2005
The efficacy of medical team training: improved team performance and decreased operating room delays: a detailed analysis of 4863 cases. September 15, 2010
Frequency of failure to inform patients of clinically significant outpatient test results. June 24, 2009
Strategies to prevent central line-associated bloodstream infections in acute-care hospitals: 2022 Update. June 22, 2022
Implementation of peer messengers to deliver feedback: an observational study to promote professionalism in nursing. January 18, 2023
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Use of unsolicited patient observations to identify surgeons with increased risk for postoperative complications. March 1, 2017
Using drug knowledgebase information to distinguish between look-alike-sound-alike drugs. June 27, 2018
Identification and characterization of failures in infectious agent transmission precaution practices in hospitals: a qualitative study. June 20, 2018
Outpatient CPOE orders discontinued due to 'erroneous entry': prospective survey of prescribers' explanations for errors. August 16, 2017
Analysis of variations in the display of drug names in computerized prescriber-order-entry systems. May 24, 2017
Computerized prescriber order entry–related patient safety reports: analysis of 2522 medication errors. October 19, 2016
Using a machine learning system to identify and prevent medication prescribing errors: a clinical and cost analysis evaluation. December 18, 2019
Effects of an online personal health record on medication accuracy and safety: a cluster-randomized trial. May 23, 2012
Striving for a zero-error patient surgical journey through adoption of aviation-style challenge and response flow checklists: a quality improvement project. February 27, 2013
The value of library and information services in patient care: results of a multisite study. March 6, 2013
Comparison of a prototype for indications-based prescribing with 2 commercial prescribing systems. May 1, 2019
Association of coworker reports about unprofessional behavior by surgeons with surgical complications in their patients. July 10, 2019
How often do prescribers include indications in drug orders? Analysis of 4 million outpatient prescriptions. July 10, 2019
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
An effort to improve electronic health record medication list accuracy between visits: patients' and physicians' response. March 19, 2008
A new tool to give hospitalists feedback to improve interprofessional teamwork and advance patient care. November 28, 2012
Specificity of computerized physician order entry has a significant effect on the efficiency of workflow for critically ill patients. April 21, 2005
TRIAD XII: are patients aware of and agree with DNR or POLST orders in their medical records. September 11, 2019
The TRANSFORM patient safety project: a microsystem approach to improving outcomes on inpatient units. May 20, 2015
Impact of introducing an electronic physiological surveillance system on hospital mortality. October 15, 2014
Relationship between physician burnout and the quality and cost of care for Medicare beneficiaries is complex. April 20, 2022
Racial and ethnic differences in emergency department pain management of children with fractures. April 22, 2020
The e-Autopsy/e-Biopsy: a systematic chart review to increase safety and diagnostic accuracy. October 26, 2022
The effect of a system-level tiered huddle system on reporting patient safety events: an interrupted time series analysis. October 12, 2022
Effect of a multifaceted clinical pharmacist intervention on medication safety after hospitalization in persons prescribed high-risk medications: a randomized clinical trial. March 17, 2021
Self-Reported Learning (SRL), a voluntary incident reporting system experience within a large health care organization. May 12, 2021
Evidence of respiratory infection transmission within physician offices could inform outpatient infection control. September 1, 2021
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
Recognizing and responding to the "toxic" work environment: worker safety, patient safety, and abuse/neglect in nursing homes. September 20, 2017
Primary care providers' opening of time-sensitive alerts sent to commercial electronic health record InBaskets. August 30, 2017
Patient safety culture transformation in a children's hospital: an interprofessional approach. April 30, 2014
Barcode medication administration work-arounds: a systematic review and implications for nurse executives. November 27, 2013
Adverse drug events after hospital discharge in older adults: types, severity, and involvement of Beers criteria medications. November 13, 2013
ACOG SCOPE: Safety Certification in Outpatient Practice Excellence for Women's Health. September 5, 2012
Improving patient safety in clinical oncology: applying lessons from Normal Accident Theory. October 21, 2015
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