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101. Investigating the impact of a pharmacist intervention on inappropriate prescribing practices at hospital admission and discharge in older patients: a secondary outcome analysis from a randomized controlled trial. | PSNet
     psnet.ahrq.gov/issue/investigating-impact-pharmacist-intervention-inappropriate-prescribing-practices-hospital
     November 30, 2022 - impact of a pharmacist intervention on inappropriate prescribing practices at hospital admission and discharge … impact of a pharmacist intervention on inappropriate prescribing practices at hospital admission and discharge … This study aimed to estimate the prevalence of PIM and PPO at hospital admission and discharge and to … Patients in the intervention group (with pharmacist involvement) had lower rates of PIM at discharge … impact of a pharmacist intervention on inappropriate prescribing practices at hospital admission and discharge

102. Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without a Plan. | PSNet
     psnet.ahrq.gov/web-mm/be-picky-about-your-piccs-fragmented-care-and-poor-communication-discharge-leads-picc
     July 19, 2023 - Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge Leads to a PICC without … Discharge follow-up did not include home health services.   … The patient confirmed that the line had not been flushed since her discharge date. … . 23   Anticipating the patient's needs at the time of discharge is essential. … Empowering patients: simplifying discharge instructions.

103. Medication Reconciliation | PSNet
     psnet.ahrq.gov/primer/medication-reconciliation
     March 15, 2025 - As a result, the new medication regimen prescribed at the time of discharge may inadvertently omit needed … care by reviewing the patient's complete medication regimen at the time of admission, transfer, and discharge … However, both the actual clinical effect of medication discrepancies after discharge appears to be small … February 28, 2024 Medication reconciliation at hospital discharge: a qualitative exploration of acute … September 11, 2024 Impact of pharmacist-led discharge medication reconciliation on error

104. Association between in-clinic opioid administration and discharge opioid prescription in urgent care: a retrospective cohort study. | PSNet
     psnet.ahrq.gov/issue/association-between-clinic-opioid-administration-and-discharge-opioid-prescription-urgent
     May 19, 2021 - Study Association between in-clinic opioid administration and discharge opioid prescription … Association between in-clinic opioid administration and discharge opioid prescription in urgent care: … received oral or intravenous opioids during an urgent care visit were more likely to receive opioids at discharge … Association between in-clinic opioid administration and discharge opioid prescription in urgent care: … November 11, 2015 Association between unmet nonmedication needs after hospital discharge

105. Implementation of a specialized pharmacy team to monitor high-risk medications during discharge. | PSNet
     psnet.ahrq.gov/issue/implementation-specialized-pharmacy-team-monitor-high-risk-medications-during-discharge
     September 23, 2020 - Implementation of a specialized pharmacy team to monitor high-risk medications during discharge … Implementation of a specialized pharmacy team to monitor high-risk medications during discharge. … commentary details the development of a medication reconciliation program to improve documentation at discharge … Implementation of a specialized pharmacy team to monitor high-risk medications during discharge. … Effect of a pharmacist intervention on clinically important medication errors after hospital discharge

106. What is an ethically informed approach to managing patient safety risk during discharge planning? | PSNet
     psnet.ahrq.gov/issue/what-ethically-informed-approach-managing-patient-safety-risk-during-discharge-planning
     November 16, 2022 - Commentary What is an ethically informed approach to managing patient safety risk during discharge … What Is an Ethically Informed Approach to Managing Patient Safety Risk During Discharge Planning? … Patient safety is a concern throughout the entire  process of care  from admission to discharge. … assure that patients return to a  home environment  that can enable their safe recovery whether the discharge … What Is an Ethically Informed Approach to Managing Patient Safety Risk During Discharge Planning?

107. Transition of care for hospitalized elderly patients—development of a discharge checklist for hospitalists. | PSNet
     psnet.ahrq.gov/issue/transition-care-hospitalized-elderly-patients-development-discharge-checklist-hospitalists
     November 16, 2022 - Commentary Transition of care for hospitalized elderly patients—development of a discharge … Transition of care for hospitalized elderly patients—Development of a discharge checklist for hospitalists … The authors describe their experience in developing a discharge checklist to standardize the process  … Transition of care for hospitalized elderly patients—Development of a discharge checklist for hospitalists … May 8, 2017 Promoting effective transitions of care at hospital discharge: a review of

108. Prescription and transcription errors in multidose-dispensed medications on discharge from hospital: an observational and interventional study. | PSNet
     psnet.ahrq.gov/issue/prescription-and-transcription-errors-multidose-dispensed-medications-discharge-hospital
     February 15, 2011 - Study Prescription and transcription errors in multidose-dispensed medications on discharge … Prescription and transcription errors in multidose-dispensed medications on discharge from hospital: … Medication reconciliation revealed a high rate of prescribing and transcribing errors in the discharge … Prescription and transcription errors in multidose-dispensed medications on discharge from hospital: … April 5, 2023 The complexities of communication at hospital discharge of older patients

109. The impact of automated notification on follow-up of actionable tests pending at discharge: a cluster-randomized controlled trial. | PSNet
     psnet.ahrq.gov/issue/impact-automated-notification-follow-actionable-tests-pending-discharge-cluster-randomized
     March 04, 2015 - Classic The impact of automated notification on follow-up of actionable tests pending at discharge … The Impact of Automated Notification on Follow-up of Actionable Tests Pending at Discharge: a Cluster-Randomized … Incomplete follow-up of tests pending at hospital discharge is a persistent patient safety issue. … Previous WebM&M commentaries explored problems related to tests pending at discharge and how organizations … Effect of digital tools to promote hospital quality and safety on adverse events after discharge

110. Reengineering hospital discharge: a protocol to improve patient safety, reduce costs, and boost patient satisfaction. | PSNet
     psnet.ahrq.gov/issue/reengineering-hospital-discharge-protocol-improve-patient-safety-reduce-costs-and-boost
     May 20, 2009 - Commentary Reengineering hospital discharge: a protocol to improve patient safety … Reengineering hospital discharge: a protocol to improve patient safety, reduce costs, and boost patient … In this commentary, AHRQ Director Carolyn Clancy discusses effective patient discharge as an important … November 8, 2012 Managing Patients' Medicines after Discharge from Hospital. … May 2, 2012 Hospital discharge documentation and risk of rehospitalisation.

111. Concept and development of a discharge alert filter for abnormal laboratory values coupled with computerized provider order entry: a tool for quality improvement and hospital risk management. | PSNet
     psnet.ahrq.gov/issue/concept-and-development-discharge-alert-filter-abnormal-laboratory-values-coupled
     June 27, 2018 - Study Concept and development of a discharge alert filter for abnormal laboratory … Concept and development of a discharge alert filter for abnormal laboratory values coupled with computerized … Adverse events after hospital discharge are a continued threat to patient safety and the basis for … Premature discharge is an area less studied, partly because the decision-making for safe discharge falls … Triggers that led to a discharge alert included an elevated white blood cell count, a rising creatinine

112. Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study. | PSNet
     psnet.ahrq.gov/issue/impact-pharmacist-facilitated-hospital-discharge-program-quasi-experimental-study
     December 21, 2014 - Study Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental … Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study. … have demonstrated a high incidence of inadvertent medication discrepancies at the time of discharge … This finding may indicate that more comprehensive discharge interventions may be necessary in order … Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study.

113. Lessons learned from implementation of a computerized application for pending tests at hospital discharge. | PSNet
     psnet.ahrq.gov/issue/lessons-learned-implementation-computerized-application-pending-tests-hospital-discharge
     March 04, 2015 - Lessons learned from implementation of a computerized application for pending tests at hospital discharge … Lessons learned from implementation of a computerized application for pending tests at hospital discharge … hospital's implementation of an electronic system to help track and manage tests pending at hospital discharge … Lessons learned from implementation of a computerized application for pending tests at hospital discharge … , 2015 Patient safety concerns arising from test results that return after hospital discharge

114. Post-discharge adverse events among African American and Caucasian patients of an urban community hospital. | PSNet
     psnet.ahrq.gov/issue/post-discharge-adverse-events-among-african-american-and-caucasian-patients-urban-community
     January 18, 2023 - Study Post-discharge adverse events among African American and Caucasian patients … Post-discharge adverse events among African American and Caucasian patients of an urban community hospital … community hospital to identify differences in the incidence of adverse events (AEs) within 30 days of discharge … The authors found that approximately 30% of both groups of patients experienced a post-discharge AE ; … Post-discharge adverse events among African American and Caucasian patients of an urban community hospital

115. Death by suicide within 1 week of hospital discharge: a retrospective study of root cause analysis reports. | PSNet
     psnet.ahrq.gov/issue/death-suicide-within-1-week-hospital-discharge-retrospective-study-root-cause-analysis
     May 04, 2022 - Study Death by suicide within 1 week of hospital discharge: a retrospective study … Death by Suicide Within 1 Week of Hospital Discharge: A Retrospective Study of Root Cause Analysis Reports … This review of root cause analysis reports about suicide within 7 days of discharge from inpatient … Death by Suicide Within 1 Week of Hospital Discharge: A Retrospective Study of Root Cause Analysis Reports … From the Same Author(s) Is it time for the mental health field to consider unplanned discharge

116. Understanding hazards for adverse drug events among older adults after hospital discharge: insights from frontline care professionals. | PSNet
     psnet.ahrq.gov/issue/understanding-hazards-adverse-drug-events-among-older-adults-after-hospital-discharge
     September 21, 2022 - Understanding hazards for adverse drug events among older adults after hospital discharge … Understanding hazards for adverse drug events among older adults after hospital discharge: insights from … medication-related harm during care transitions, including complex dosing, knowledge gaps, errors in discharge … Understanding hazards for adverse drug events among older adults after hospital discharge: insights from … November 2, 2022 Drug-drug interactions and prescription appropriateness at hospital discharge

117. A quality improvement initiative to improve pediatric discharge medication safety and efficiency. | PSNet
     psnet.ahrq.gov/issue/quality-improvement-initiative-improve-pediatric-discharge-medication-safety-and-efficiency
     May 20, 2020 - Study A quality improvement initiative to improve pediatric discharge medication … A quality improvement initiative to improve pediatric discharge medication safety and efficiency. … This quality improvement found that increased utilization of a patient-friendly discharge medication … platform integrated into the electronic health record (EHR) system was associated with improved inpatient discharge … A quality improvement initiative to improve pediatric discharge medication safety and efficiency.

118. Communication of incidental imaging findings on inpatient discharge summaries after implementation of electronic health record notification system. | PSNet
     psnet.ahrq.gov/issue/communication-incidental-imaging-findings-inpatient-discharge-summaries-after-implementation
     August 19, 2020 - Study Communication of incidental imaging findings on inpatient discharge summaries … Communication of incidental imaging findings on inpatient discharge summaries after implementation of … with incidental imaging findings (IIF) were reviewed to determine if IIFs were included on hospital discharge … Approximately half of discharge summaries mentioned IIFs, and most patients and providers (79%) were … Communication of incidental imaging findings on inpatient discharge summaries after implementation of

119. Analysis of the nature and contributory factors of medication safety incidents following hospital discharge using National Reporting and Learning System (NRLS) data from England and Wales: a multi-method study. | PSNet
     psnet.ahrq.gov/issue/analysis-nature-and-contributory-factors-medication-safety-incidents-following-hospital
     October 25, 2023 - Analysis of the nature and contributory factors of medication safety incidents following hospital discharge … Analysis of the nature and contributory factors of medication safety incidents following hospital discharge … Medication errors and adverse drug events (ADE) are unfortunately common at hospital discharge . … Analysis of the nature and contributory factors of medication safety incidents following hospital discharge … designed to improve medication safety for patients with monitored dosage systems following hospital discharge

120. Improving the quality of discharge communication with an educational intervention. | PSNet
     psnet.ahrq.gov/issue/improving-quality-discharge-communication-educational-intervention
     April 24, 2018 - Study Improving the quality of discharge communication with an educational intervention … Improving the quality of discharge communication with an educational intervention. … After an educational intervention, pediatric residents' discharge summaries were more concise yet contained … more information about key care transitions issues, such as tests pending at discharge . … Improving the quality of discharge communication with an educational intervention.