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psnet.ahrq.gov/issue/physician-reporting-clinically-significant-events-through-computerized-patient-sign-out
January 25, 2023 - Study
Physician reporting of clinically significant events through a computerized patient sign-out system.
Citation Text:
Nabors C, Peterson SJ, Aronow WS, et al. Physician reporting of clinically significant events through a computerized patient sign-out system. J Patient Saf. 2011;7(…
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psnet.ahrq.gov/issue/using-who-international-classification-patient-safety-framework-identify-incident
January 15, 2020 - Journal Article
Using the WHO International Classification of patient safety framework to identify incident characteristics and contributing factors for medical or surgical complication deaths
Citation Text:
Mitchell R, Faris M, Lystad R, et al. Using the WHO International Classification…
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psnet.ahrq.gov/perspective/conversation-witheric-coleman-md-mph
December 01, 2007 - The most powerful efforts to improve patient discharge and transitions of care will have the full support … Although it is likely that an investment in discharge planning and postdischarge support will be cost-effective
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psnet.ahrq.gov/node/49813/psn-pdf
January 01, 2018 - Dying in the Hospital With Advanced Dementia
December 1, 2017
Umscheid CA, McGreevey JD, Greysen RS. Dying in the Hospital With Advanced Dementia. PSNet
[internet]. 2017.
https://psnet.ahrq.gov/web-mm/dying-hospital-advanced-dementia
Case Objectives
Recognize the importance of eliciting patient preferences and go…
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psnet.ahrq.gov/issue/using-incident-reports-assess-communication-failures-and-patient-outcomes
February 06, 2019 - What is an ethically informed approach to managing patient safety risk during discharge … planning?
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psnet.ahrq.gov/sites/default/files/2020-02/final_spotlight_opat_powerpoint_01102020_tocme.pdf
January 01, 2020 - Spotlight
Spotlight
Discharged with IV antibiotics:
When issues arise, who manages
the complications?
Source and Credits
• This presentation is based on the February 2020 AHRQ
WebM&M Spotlight Case
○ See the full article at https://psnet.ahrq.gov/webmm
○ CME credit is available
• Commentary by: Monica Donnel…
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psnet.ahrq.gov/issue/what-patients-think-doctors-know-beliefs-about-provider-knowledge-barriers-safe-medication
November 26, 2014 - Study
What patients think doctors know: beliefs about provider knowledge as barriers to safe medication use.
Citation Text:
Serper M, McCarthy D, Patzer RE, et al. What patients think doctors know: beliefs about provider knowledge as barriers to safe medication use. Patient Educ Couns.…
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psnet.ahrq.gov/issue/usability-computerised-drug-monitoring-programme-detect-adverse-drug-events-and-non
December 21, 2014 - Study
Usability of a computerised drug monitoring programme to detect adverse drug events and non-compliance in outpatient ambulatory care.
Citation Text:
Auger C, Forster AJ, Oake N, et al. Usability of a computerised drug monitoring programme to detect adverse drug events and non-comp…
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psnet.ahrq.gov/issue/high-prevalence-medication-discrepancies-between-home-health-referrals-and-centers-medicare
December 23, 2011 - Study
High prevalence of medication discrepancies between home health referrals and Centers for Medicare and Medicaid Services home health certification and plan of care and their potential to affect safety of vulnerable elderly adults.
Citation Text:
Brody AA, Gibson B, Tresner-Kirsch D…
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psnet.ahrq.gov/issue/risks-analogue-and-digitally-supported-medication-process-and-potential-solutions-increase
April 24, 2019 - Study
Risks in the analogue and digitally-supported medication process and potential solutions to increase patient safety in the hospital: a mixed methods study.
Citation Text:
Kopanz J, Lichtenegger K, Schwarz CM, et al. Risks in the analogue and digitally-supported medication process a…
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psnet.ahrq.gov/issue/using-targeted-solutions-toolr-improve-emergency-department-handoffs-community-hospital
April 13, 2022 - Study
Using the Targeted Solutions Tool® to improve emergency department handoffs in a community hospital.
Citation Text:
Benjamin MF, Hargrave S, Nether K. Using the Targeted Solutions Tool® to Improve Emergency Department Handoffs in a Community Hospital. Jt Comm J Qual Patient Saf. 2…
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psnet.ahrq.gov/node/853080/psn-pdf
August 30, 2023 - The virtual nurse’s role in admissions and discharge planning could help prevent such
gaps.1,2
Virtual
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psnet.ahrq.gov/issue/mixed-methods-study-examining-teamwork-shared-mental-models-interprofessional-teams-during
January 08, 2020 - Study
A mixed methods study examining teamwork shared mental models of interprofessional teams during hospital discharge.
Citation Text:
Manges K, Groves PS, Farag A, et al. A mixed methods study examining teamwork shared mental models of interprofessional teams during hospital discharge…
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psnet.ahrq.gov/innovation/enhancing-support-patients-social-needs-reduce-hospital-readmissions-and-improve-health
February 26, 2025 - community partners and tracked updates in a shared database for recording patient progress and needs after patient … discharge.
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psnet.ahrq.gov/issue/best-medicine-fixing-modern-hospital
February 06, 2008 - Newspaper/Magazine Article
The best medicine for fixing the modern hospital.
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December 12, 2012
View more articles from the same auth…
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psnet.ahrq.gov/web-mm/steroids-and-safety-preventing-medication-adverse-events-during-transitions-care
September 09, 2013 - interventions span the entire transitional period and include elements of medication reconciliation, discharge … planning, patient (and family/caregiver) discharge education, health and general literacy awareness,
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psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture
January 29, 2020 - Management
November 1, 2011
Patient Safety Primers
Discharge … Planning and Transitions of Care
March 25, 2020
WebM&M Cases
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psnet.ahrq.gov/issue/clinical-pharmacist-led-transitions-care-program-veterans-two-planned-care-transitions
December 23, 2011 - Study
A clinical pharmacist-led transitions of care program for veterans with two planned care transitions (hospital to skilled care and skilled care to home) amid the COVID-19 pandemic.
Citation Text:
Scannell GA, Bevan DJ, Cowan A, et al. A clinical pharmacist-led transitions of care p…
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psnet.ahrq.gov/web-mm/sepsis-resulting-delays-treatment-and-miscommunication-among-specialists
February 26, 2025 - Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists
Citation Text:
Shi L, Noren E. Sepsis Resulting from Delays in Treatment and Miscommunication among Specialists. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Se…
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psnet.ahrq.gov/issue/failure-follow-medication-changes-made-hospital-discharge-associated-adverse-events-30-days
October 16, 2019 - Study
Failure to follow medication changes made at hospital discharge is associated with adverse events in 30 days.
Citation Text:
Weir DL, Motulsky A, Abrahamowicz M, et al. Failure to follow medication changes made at hospital discharge is associated with adverse events in 30 days. Hea…