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21. Computerized order entry with limited decision support to prevent prescription errors in a PICU. | PSNet
    psnet.ahrq.gov/issue/computerized-order-entry-limited-decision-support-prevent-prescription-errors-picu
    January 31, 2018 - 2005 Clinical outcomes from the use of Medication Report when elderly patients are discharged … 2009 Medication report reduces number of medication errors when elderly patients are discharged … October 4, 2017 Medication errors by caregivers at home in neonates discharged from the

22. Medication errors in the emergency department: need for pharmacy involvement? | PSNet
    psnet.ahrq.gov/issue/medication-errors-emergency-department-need-pharmacy-involvement
    April 24, 2024 - March 30, 2022 Antibiotic prescribing errors in patients discharged from the pediatric … November 10, 2021 Incidence of prescription errors in patients discharged from the emergency

23. Emergency department discharge prescription interventions by emergency medicine pharmacists. | PSNet
    psnet.ahrq.gov/issue/emergency-department-discharge-prescription-interventions-emergency-medicine-pharmacists
    March 04, 2009 - This cohort study found that ED pharmacists intervened in 10.1% of prescriptions written for patients discharged … March 2, 2022 Incidence of prescription errors in patients discharged from the emergency … December 9, 2020 Antibiotic prescribing errors in patients discharged from the pediatric … March 30, 2022 Antibiotic prescribing errors in patients discharged from the pediatric … December 1, 2021 Incidence of prescription errors in patients discharged from the emergency

24. Rx drug error may affect 2,000 patients. | PSNet
    psnet.ahrq.gov/issue/rx-drug-error-may-affect-2000-patients
    September 02, 2009 - This article reports on a software malfunction that caused prescription errors affecting patients discharged

25. Clinical Pharmacy Specialists Provide Transitional Care and Improve Medication Safety After Discharge at Memphis Veterans Affairs Medical Center | PSNet
    psnet.ahrq.gov/innovation/clinical-pharmacy-specialists-provide-transitional-care-and-improve-medication-safety
    April 24, 2024 - led by clinical pharmacy specialists (CPSs) who provide follow-up care to patients after they are discharged … effective in reducing readmissions. 3,4,5,6 The target population for this innovation included recently discharged … Care coordination with the patient’s providers Scheduling TCC appointments before the patient is discharged … After the TCC appointment, patients were discharged to their primary care team or specialty provider … Care coordination with the patient’s providers Scheduling TCC appointments before the patient is discharged

26. Discharge Against Medical Advice | PSNet
    psnet.ahrq.gov/web-mm/discharge-against-medical-advice
    July 01, 2017 - two groups.( 5 ) No specific factors have been found to strongly predict readmission among patients discharged … risk of death, as no study has compared mortality rates among patients leaving AMA to those formally discharged … rates and may be at increased risk of serious adverse health consequences when compared with normally discharged … Patients discharged against medical advice from a general medicine service. … Characteristics of patients with pneumonia who are discharged from hospitals against medical advice.

27. Readmissions and Adverse Events After Discharge | PSNet
    psnet.ahrq.gov/primer/readmissions-and-adverse-events-after-discharge
    September 07, 2019 - Twitter Linkedin Copy URL September 7, 2019 Background Being discharged … More subtle discharge hazards arise from the fact that nearly 40% of patients are discharged with test … results pending , and a comparable proportion are discharged with a plan to complete the diagnostic

28. Spotlight (pdf file)
    psnet.ahrq.gov/sites/default/files/2022-10/spotlight_case_missed_pneumothorax_10.09.2022_-_final.pdf
    January 01, 2022 - • The patient was discharged home with family members, with instructions to follow up “as needed, … • The patient was admitted overnight for observation and discharged the next day after treatment … expected recovery trajectory, and the milestones that must be achieved before the patient can be safely discharged … response from the radiologist was too late to ensure patient safety, as it occurred after the patient was discharged … interpretation and communication of the CXR results did not happen until after the patient had been discharged

29. Spotlight Case [MONTH] 2003 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.227_slideshow.ppt
    November 01, 2010 - He was switched to trimethoprim-sulfamethoxazole, an antibiotic he could take by mouth, and discharged … Treatment after Discharge (2) * * Transitions in Care 2.3 million ED visits each year by patients discharged … Emergency department visits by persons recently discharged from U.S. hospitals.

30. Early death after discharge from emergency departments: analysis of national US insurance claims data. | PSNet
    psnet.ahrq.gov/issue/early-death-after-discharge-emergency-departments-analysis-national-us-insurance-claims-data
    June 30, 2021 - claims data found that a significant number of adults age 65–89 died within a week of visiting and being discharged … proportion of emergency department patients to the inpatient setting had a higher mortality rate among discharged … relating patient outcomes to volume , higher-volume emergency departments had lower 7-day mortality among discharged … A WebM&M commentary discussed an incident involving a patient who died after being discharged from

31. Assessment of the safety of discharging select patients directly home from the intensive care unit: a multicenter population-based cohort study. | PSNet
    psnet.ahrq.gov/issue/assessment-safety-discharging-select-patients-directly-home-intensive-care-unit-multicenter
    May 20, 2020 - Overall, patients discharged from the ICU to home are younger and less ill than patients who are transferred … The proportion of patients discharged from ICU to home varied widely by site. … When researchers compared patients discharged from ICU to home to patients of similar age and severity … of illness upon ICU admission who were discharged home from the hospital ward, they found no differences

32. Critical Echocardiogram Result Lost to Follow-up. | PSNet
    psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow
    July 31, 2023 - review, the echocardiogram results had populated into the electronic health record after the patient was discharged … patient at the time also did not follow up the patient’s echocardiogram given that he had already been discharged … case revealed several figurative Swiss cheese holes that aligned: the patient had already been discharged … If the patient has already been discharged, the interpreting physician could contact the patient’s primary … If the patient had already been discharged, they would contact the patient’s primary care provider and

33. Postdischarge Follow-Up Phone Call | PSNet
    psnet.ahrq.gov/web-mm/postdischarge-follow-phone-call
    February 01, 2019 - The patient improved rapidly over 48 hours and was discharged home (she lived with her daughter and grandson … That afternoon, she received a phone call from the hospital where she had been discharged. … At this hospital, all patients discharged from the medicine service are called by a nurse within 3 days … target only high-risk patients, for example, elderly patients, those with certain diagnoses, or those discharged … follow-up, initiated by a hospital-based health professional, for postdischarge problems in patients discharged

34. Spotlight Case July 2008 (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.263_slideshow.ppt
    March 01, 2012 - The patient improved rapidly over 48 hours and was discharged home (she lived with her daughter and grandson … (All patients discharged from medicine service at this hospital are called by a nurse within 3 days.) … follow-up, initiated by a hospital-based health professional, for postdischarge problems in patients discharged … follow-up, initiated by a hospital-based health professional, for post-discharge problems in patients discharged

35. Insulin Administration: Pen vs Vial – Similar, but Not Interchangeable | PSNet
    psnet.ahrq.gov/web-mm/insulin-administration-pen-vs-vial-similar-not-interchangeable
    November 30, 2023 - After a three-day hospital stay, the patient was ready to be discharged and the medications intended … Improving the quality of insulin prescribing for people with diabetes being discharged from hospital. … : a systematic review May 20, 2020 WebM&M Cases Discharged … 2019 Improving the quality of insulin prescribing for people with diabetes being discharged

36. Action research, simulation, team communication, and bringing the tacit into voice. Society for Simulation in Healthcare. | PSNet
    psnet.ahrq.gov/issue/action-research-simulation-team-communication-and-bringing-tacit-voice-society-simulation
    October 03, 2018 - 2018 Clinical outcomes from the use of Medication Report when elderly patients are discharged … 2009 Medication report reduces number of medication errors when elderly patients are discharged

37. Preventable Transfer to the Hospital | PSNet
    psnet.ahrq.gov/web-mm/preventable-transfer-hospital
    March 31, 2022 - He was eventually discharged to a skilled nursing facility (SNF); however, he was readmitted approximately … progressively shorter despite the increasing complexity of patients, and as a result, patients are often discharged … for High-Risk Patients When compared to their counterparts who go home from the hospital, patients discharged … contribute to adverse events within the first few weeks after hospital discharge. 9 Indeed, 23% of patients discharged

38. PowerPoint Presentation (ppt file)
    psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.17_slideshow.ppt
    June 01, 2003 - She was diagnosed with gastroenteritis, discharged with antiemetics, and told to return for persistent … On hospital day #13, she was discharged home with a plan to follow-up for elective appendectomy. … Eight days later, the patient was discharged home.

39. Medication errors: prescriptions for safety. | PSNet
    psnet.ahrq.gov/issue/medication-errors-prescriptions-safety
    October 29, 2014 - Citation Related Resources Potentially inappropriate prescribing in older patients discharged

40. False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy. | PSNet
    psnet.ahrq.gov/web-mm/false-assumptions-result-missed-pneumothorax-after-bronchoscopy-transbronchial-biopsy
    March 15, 2023 - The patient was discharged home with family members, with instructions to follow up “as needed,” as his … The patient was admitted overnight for observation and discharged the next day after treatment with supplemental … expected recovery trajectory, and the milestones that must be achieved before the patient can be safely discharged … response from the radiologist was too late to ensure patient safety as it occurred after the patient was discharged … interpretation and communication of the CXR results did not happen until after the patient had been discharged