LIBRARY: Analysis of CDCR Death Reviews 2006: Public Version

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Analysis of CDCR Death Reviews 2006: Public Version

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Analysis of CDCR Death Reviews 2006: Public Version

Downloaded 18 times since 10/05/2007.

Imai, Kent

California Prison Health Care Receivership Corp. (San Jose, CA)

Published 2007. 11 pages.

Death review reports from 2006 are examined for individual practitioner and systemic deficiencies of care leading to patient deaths in order to make recommendations for optimal medical safety and patient care. Sections comprising this report are: background; purpose; limitations; definitions; findings regarding causes of and lapses in care in cases of non-preventable death, preventable death, and possibly preventable deaths; discussion concerning lapses in care (e.g., individual practitioner errors in judgment or attitude, systemic lapses, and "no-fault" lapses), trends in preventable deaths over time and comment on agency environment of care; and fourteen recommendations. Accession Number: 022567

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