Article thumbnail

Patterns of unexpected in-hospital deaths: a root cause analysis

By Lawrence A Lynn and J Paul Curry
Topics: Review
Publisher: BioMed Central
OAI identifier:
Provided by: PubMed Central

To submit an update or takedown request for this paper, please submit an Update/Correction/Removal Request.

Suggested articles


  1. (2003). A: Opioid-induced respiratory depression is associated with increased tidal volume variability.
  2. (1971). Acid-base balance in bacteremic shock.
  3. (2007). Activation of opioid mu receptors in caudal medullary raphe region inhibits the ventilatory response to hypercapnia in anesthetized rats. Anesthesiology
  4. al: Pharmacokinetics of Morphine; Effects of.
  5. (2010). Alarm fatigue sets off bells. Mass. incident highlights need for protocols check. Mod Health
  6. (1999). AM: Repetitive hypoxia rapidly depresses cardio-respiratory responses during active sleep but not quiet sleep in the newborn lamb.
  7. (2010). Arterial base deficit in pulmonary embolism is an index of severity and diagnostic delay. Intern Emerg Med
  8. (2010). Blike GT: Impact of pulse oximetry surveillance on rescue events and intensive care unit transfers: a beforeand-after concurrence study. Anesthesiology
  9. (1998). Bossink Ailko WJ: Prediction of Mortality in Febrile Medical Patients How Useful Are Systemic Inflammatory Response Syndrome and Sepsis Criteria? CHEST
  10. (1995). Brodecky V: Effect of venous oxygenation on arterial desat rate during repetitive apneas in lambs. Respir Physiol
  11. (1984). Cardiopulmonary response of the rat to gram-negative bacteremia.
  12. (1987). Changes in central hemodynamics during experimental septic shock in conscious rats. Circ Shock
  13. (1998). Cluster Analysis a New Technology for The Evaluation of Oximetry Waveforms in obstructive Sleep Apnea. Sleep and Breathing
  14. (2007). Continuous oximetry/capnometry monitoring reveals frequent desaturation and bradypnea during patient-controlled analgesia. Anesth Analg
  15. (2003). Contributions of Upper Airway Mechanics and Control Mechanisms to Severity of Obstructive apnea.
  16. (1991). De Lisser EA: Sleep apnea syndromes: a potential contraindication for patient-controlled analgesia. Anesthesiology
  17. (2006). DE: PHOX2B mutation-confirmed congenital central hypoventilation syndrome: presentation in adulthood. Am J Respir Crit Care Med
  18. (2008). Defining the Incidence of Cardiorespiratory Instability in Patients in Step-down Units Using an Electronic Integrated Monitoring System. Arch Intern Med
  19. (2005). Diaphragmatic fatigue during sepsis and septic shock. Intensive Care Med
  20. (1995). Diestelhorst C: The effect of sedation on pulmonary function. Anaesthesist
  21. (2009). Early recognition of myxedematous respiratory failure in the elderly.
  22. (2007). Editor: Integrated monitoring and analysis for early warning of patient deterioration.
  23. (2009). Editors: Computation Technology for Effective Health Care: Immediate Steps and Strategic Directions. National Research Council of the National Academies;
  24. (2003). et al: 5-HT Receptors Avert Opioid-induced Breathing Depression without Loss of Analgesia. Science
  25. (2009). et al: Capnography monitoring in nonintubated patients with respiratory distress.
  26. (1978). et al: Pathogenesis of Upper Airway Occlusion During Sleep.
  27. (1967). et al: Patterns of septic shock in man: A detailed study of 56 patients. Ann Surg
  28. (1993). et al: Randomized evaluation of pulse oximetry in 20,802 patients: II. Perioperative events and postoperative complications. Anesthesiology
  29. (2009). Evaluation of endtidal carbon dioxide role in predicting elevated SOFA scores and lactic acidosis. Intern Emerg Med
  30. Evaluation of rapid response team flag-alert parameters.
  31. (2010). FernándezRodríguez CM: Capnography is superior to pulse oximetry for the detection of respiratory depression during colonoscopy. Rev Esp Enferm Dig
  32. (2008). Finn MKathleen, et al: A Controlled Trial of a Rapid Response System in an Academic Medical Center. The Joint Commission Journal on Quality and Patient Safety.
  33. (2005). Granja CA: The sensitivity of room-air pulse oximetry in the detection of hypercapnia.
  34. (1960). Guze LB: Hyperventilation and respiratory alkalosis as signs of gram-negative bacteremia.
  35. (2004). HA: Obstructive sleep apnea associated with cerebral hypoxemia and death. Neurology
  36. Has oxygen administration delayed appropriate respiratory care? In Respir Care. Volume 48. Fallacies regarding oxygen therapy;
  37. (2005). Hellier E: Fewer but better auditory alarms will improve patient safety. Qual Safe Health Care
  38. (2005). Higgins TL: New-generation pulse oximetry in the care of critically ill patients.
  39. (2009). Horner RL: Opioid receptor mechanisms at the hypoglossal motor pool and effects on tongue muscle activity in vivo.
  40. (1970). Hypocapnia and gram-negative bacteremic shock. AmJ Surg
  41. (2002). Interpretive oximetry: future directions for diagnostic applications of the SpO2 time-series. Anesth Analg
  42. (2001). Kirvelä OA: The concentration-effect relationship of the respiratory depressant effects of alfentanil and fententanil. Anesth Analg
  43. (1968). KP: The role of the central nervous system in septic shock. II. Hemodynamic, respiratory and metabolic effects of intracisternal or intraventricular endotoxin. Ann Surg
  44. (2007). LK: Sleep-related hypoventilation/hypoxemic syndromes. Chest
  45. (2008). Longmore SLance, Berg ARobert, Kosiborod Mikhail, Spertus AJohn: Hospital-wide Code Rates and Mortality Before and After Implementation of a Rapid Response Team. JAMA
  46. (1956). Medicine (Baltimore): Carbon dioxide intoxication: the clinical syndrome, its etiology and management with particular reference to the use of mechanical respirators.
  47. (2009). Mokhlesi B: The pickwickian syndrome-obesity hypoventilation syndrome. Clin Chest Med
  48. (2010). Monitor alarm fatigue: standardizing use of physiological monitors and decreasing nuisance alarms.
  49. (2010). Monitor alarm fatigue.
  50. (2002). Motion-resistant” pulse oximetry: a comparison of new and old models. Anesth Analg
  51. (1999). Namiki A: Changes in respiratory pattern and arterial blood gases during sedation with propofol or midazolam in spinal anesthesia.
  52. (2010). O’Donnell CP: Pathophysiology of sleep apnea. Physiol Rev.
  53. (2009). Obstructive Sleep Apnea Presenting as Recurrent Cardiopulmonary Arrest. Sleep Breath
  54. (2005). Obstructive sleep apnea uncovered after high spinal anesthesia: a case report.
  55. (2009). Opioid-induced suppression of genioglossal muscle activity: is it clinically important?
  56. (1995). PF: Sedative and ventilatory effects of midazolam infusion: effect of flumazenil reversal.
  57. (2007). Physiological Monitoring for Critically Ill Patients: Testing a Predictive Model for the Early Detection of Sepsis.
  58. (2010). Pronovost JPeter: Commentary, Rethinking Rapid Response Teams. JAMA
  59. (2004). Prospective controlled trial of effect of medical emergency team on postoperative morbidity and mortality rates. Crit Care Med
  60. (2009). PS: Jt Comm J Qual Patient Saf. Clinical triggers: an alternative to a rapid response team
  61. (2001). Pulmonary embolism during laparoscopic cholecystectomy detected by sudden decrease in end-tidal carbon dioxide pressure. Masui
  62. (2009). Pulse Oximeter Standards Document.
  63. (2009). Pulse oximetry for perioperative monitoring. Cochrane Database Syst Rev
  64. (1991). Puschett JB: Acid-base disturbances in cardiogenic pulmonary edema. Nephron
  65. (2004). RA: Supplemental oxygen impairs detection of hypoventilation by pulse oximetry. Chest
  66. (1961). Radio telemetry in patient monitoring. Anesthesiology
  67. (2010). Rapid Response Teams: A Systematic Review and Meta-analysis. Arch Intern Med
  68. (2005). Reduction of paediatric in-patient car diac arrest and death with a medical emergency team: preliminary results. Arch Dis Child
  69. (1980). Respiratory effects of analgesia after cholecystectomy: comparison of continuous and intermittent papaveretum. Br Med J
  70. (1982). Respiratory failure after endotoxin infusion in sheep: Lung mechanics and lung fluid balance.
  71. (2008). Risk factors for the development of acute lung injury in patients with septic shock: an observational cohort study. Crit Care Med
  72. (2006). Role of Morphine’s Metabolites in Analgesia: Concepts and Controversies.
  73. (1995). RW: Triazolam in patients with obstructive sleep apnea.
  74. (2001). Scammell TE: The Sleep Switch: Hypothalamic Control of Sleep and Wakefulness. Trends. Neuroscience
  75. (2009). Scharf SM: Opioid-associated central sleep apnea: a case series. Sleep Breath
  76. (1996). Sepsis/septic shock: participation of the microcirculation: an abbreviated review. Crit Care Med
  77. (2009). Serum lactate is associated with mortality in severe sepsis independent of organ failure and shock. Crit Care Med
  78. (2002). SG: Some factors affecting cerebral tissue saturation during obstructive sleep apnoea. Eur Respir J
  79. (2004). Simmons RL: Use of medical emergency team responses to reduce hospital car diopulmonary arrests. Qual Saf Health Care
  80. (2006). SJ: The impact of continuous pulse oximetry monitoring on intensive care unit admissions from a postsurgical care floor. Anesth Analg
  81. (2002). Sleep Apnea and Narcotic Postoperative Pain Medication: A Morbidity and Mortality Risk.
  82. (1983). Sustained hypermetabolic sepsis in rats: characterization of the model. J Surg Res
  83. Taleb: Fooled by Randomness.
  84. (2007). Taleb: The Black Swan.
  85. (1989). TD: The PaCO2 rate of rise in anesthetized patients with airway obstruction.
  86. (1973). The Bohr effect and the Haldane effect.
  87. (2009). The correlation and level of agreement between endtidal and blood gas pCO2 in children with respiratory distress: a retrospective analysis. BMC Pediatr
  88. (2001). The haemodynamics of human septic shock. Anaesthesia
  89. (2009). The impact of obesity on oxygen desaturation during sleepdisordered breathing.
  90. (1976). The Selfish Gene
  91. (1962). The Structure of Scientific Revolutions. Univ. of Chicago Press;
  92. (2010). The temporal evolution of acute respiratory distress syndrome following shock.
  93. (1998). Unrecognized severe postoperative hypercapnia: a case of apneic oxygenation. Mayo Clin Proc
  94. (1987). Young EJ: Manifestations of sepsis. Arch Intern Med
  95. (1998). YS: Peripheral neural modulation of endotoxininduced hyperventilation. Crit Care Med