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psnet.ahrq.gov/issue/medication-related-emergency-department-visits-pediatrics-prospective-observational-study
October 16, 2013 - Children with a medication-related ED visit were much more likely to be admitted to the hospital and … Resources From the Same Author(s)
Medication-related emergency department visits and hospital … and adverse events in older patients admitted to hospital: a retrospective cohort study. … hospital practice: factors associated with turnover, outcomes, and patient safety. … View More
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Emergency Departments
Children's Hospitals
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psnet.ahrq.gov/issue/veterans-affairs-initiative-prevent-methicillin-resistant-staphylococcus-aureus-infections
February 22, 2017 - Health care–associated infections remain one of the most common preventable adverse events in hospitals … Although the overall incidence of hospital-acquired MRSA infections has been decreasing nationwide, … August 4, 2021
Incidence and trends of sepsis in US hospitals using clinical vs claims … a multistate hospital network--13 academic medical centers, April-June 2020. … April 1, 2010
Implementing patient safety initiatives in rural hospitals.
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psnet.ahrq.gov/issue/using-computerized-provider-order-entry-and-clinical-decision-support-improve-referring
August 20, 2018 - US hospitals using clinical vs claims data, 2009--2014. … July 29, 2020
Adequacy of hospital discharge summaries in documenting tests with pending … two 'early adopter' hospitals. … March 10, 2011
Use of electronic health records in US hospitals. … August 18, 2010
Systematically improving physician assignment during in-hospital transitions
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psnet.ahrq.gov/issue/impact-structured-interdisciplinary-bedside-rounding-patient-outcomes-large-academic-health
December 09, 2020 - use at 60 United States hospitals: a descriptive study. … of a refined evidence-based toolkit and mentored implementation on medication reconciliation at 18 hospitals … October 14, 2020
Medication-related interventions delivered both in hospital and following … June 24, 2020
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Researchers
Hospitals … Quality and Safety Professionals
Hospital Medicine
Nurse Care
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psnet.ahrq.gov/issue/medsafer-study-electronic-decision-support-deprescribing-hospitalized-older-adults-cluster
July 31, 2019 - In this cluster randomized trial, older adults (≥65 years) taking at least five medications at hospital … Despite an increase in deprescribing in both groups, there was no difference in adverse drug events or … a multistate hospital network--13 academic medical centers, April-June 2020. … October 4, 2023
Drug-drug interactions and prescription appropriateness at hospital discharge … October 1, 2008
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Hospitals
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psnet.ahrq.gov/web-mm/hard-swallow
April 26, 2023 - In keeping with standard practice at the hospital, speech pathologists, respiratory therapists, and physical … However, the responsibility hardly falls on the speech therapist alone. … The hospital where this case occurred has suggested an organizational solution to the problem. … Hospitals and clinicians should be cautious of quick fixes or reliance on a single prevention technique … August 1, 2006
There's no place like home--integrating a pharmacist into the hospital-in-home
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psnet.ahrq.gov/perspective/conversation-gordon-schiff-md
February 26, 2025 - When I was at Cook County Health and Hospital System, I chaired the Pharmacy and Therapeutics Committee … Certainly we do not have good metrics for judging hospitals or individual clinicians rates of diagnostic … You could not easily miss that a patient had a falling hematocrit. … That's one place in which my hospital, Brigham, is a leader. … MD, MPH
December 1, 2013
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Hospitals
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psnet.ahrq.gov/node/33861/psn-pdf
July 01, 2018 - When I was at Cook County Health and
Hospital System, I chaired the Pharmacy and Therapeutics Committee … Sometimes I won't hear about a patient that I missed with
back pain that ended up at another hospital … https://www.ncbi.nlm.nih.gov/pubmed/5338568
have good metrics for judging hospitals or individual … You could not easily miss that a
patient had a falling hematocrit. … That's one place in which my
hospital, Brigham, is a leader.
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psnet.ahrq.gov/periodic-issue/weekly-resource
March 25, 2025 - Falls and delays in diagnosis, treatment, or surgery were the most common adverse events related to communication … The largest category was delays in care, and 90% of incidents resulted in no harm. … Falls and delays in diagnosis, treatment, or surgery were the most common adverse events related to communication … Review
Decision fatigue in hospital settings: a scoping review. … Moving patients from one part of the hospital to another introduces clinical, communication and environmental
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psnet.ahrq.gov/issue/physician-transition-care-benefits-i-pass-and-electronic-handoff-system-community-pediatric
November 02, 2022 - In this study, implementation of I-PASS within an electronic medical record resulted in an improvement … Assessment of a wearable fall prevention system at a Veterans Health Administration hospital … The quality of 'Learning from Deaths' reporting in quality accounts within the NHS in England 2017-2020 … November 1, 2018
Improving communication with primary care physicians at the time of hospital … September 1, 2006
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Children's Hospitals
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psnet.ahrq.gov/issue/prospective-observational-study-physician-handoff-intensive-care-unit-ward-patient-transfers
October 08, 2013 - a multistate hospital network--13 academic medical centers, April-June 2020. … Developing a programme for medication reconciliation at the time of admission into hospital … June 1, 2011
Medication reconciliation during internal hospital transfer and impact of … September 9, 2009
Medication reconciliation at hospital discharge: evaluating discrepancies … View More
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Intensive Care Units
Specialty Hospitals
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psnet.ahrq.gov/issue/primer-pdsa-executing-plan-do-study-act-cycles-practice-not-just-name
December 04, 2016 - in name. … the implementation of a hospital safety programme. … March 13, 2013
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Related Resources
What US hospitals are … acute hospital settings—limited evidence of effectiveness. … November 2, 2011
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Hospitals
Facility
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psnet.ahrq.gov/issue/analysis-consistency-emergency-department-physician-variation-propensity-admission-across
May 19, 2021 - This analysis of 4.5 million emergency department visits in the US showed variation in hospital admission … at US Children's Hospitals, 2016-2019. … January 12, 2022
Effect of medication reconciliation at hospital admission on 30-day … returns to hospital: a randomized clinical trial. … June 30, 2021
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Related Resources
Hospitals in two states
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psnet.ahrq.gov/issue/programmable-infusion-pumps-icus-analysis-corresponding-adverse-drug-events
January 16, 2008 - two hospitals. … two US hospitals. … June 15, 2011
Contributing factors identified by hospital incident report narratives. … April 27, 2022
Families as partners in hospital error and adverse event surveillance. … a specialty cardiac hospital.
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psnet.ahrq.gov/issue/effects-skilled-nursing-facility-structure-and-process-factors-medication-errors-during
April 24, 2018 - hospital error and adverse event surveillance. … a multistate hospital network--13 academic medical centers, April-June 2020. … March 9, 2022
Adverse events in long-term care residents transitioning from hospital … living in nursing homes: a systematic review. … June 13, 2011
Medication discrepancies upon hospital to skilled nursing facility transitions
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psnet.ahrq.gov/issue/relationship-between-preventability-death-after-coronary-artery-bypass-graft-surgery-and-all
September 23, 2020 - be preventable based on retrospective review, preventable deaths were not correlated with individual hospital … a multistate hospital network--13 academic medical centers, April-June 2020. … November 16, 2022
Families as partners in hospital error and adverse event surveillance … October 5, 2022
Mortality due to hospital-acquired infection after cardiac surgery. … Device
September 1, 2007
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Hospitals
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psnet.ahrq.gov/issue/integrative-review-exploring-perceptions-patients-and-healthcare-professionals-towards
March 06, 2019 - promoting hand hygiene compliance in the hospital setting. … promoting hand hygiene compliance in the hospital setting. … promoting hand hygiene compliance in the hospital setting. … July 25, 2018
Medication errors in hospitals: a literature review of disruptions to nursing … July 23, 2010
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Hospitals
Physicians
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psnet.ahrq.gov/issue/experiences-diagnostic-delay-among-underserved-racial-and-ethnic-patients-systematic-review
November 03, 2015 - In this review of quantitative studies conducted in the US, patients and caregivers in underserved communities … March 4, 2015
Safety through redundancy: a case study of in-hospital patient transfers … November 2, 2010
Last orders: follow-up of tests ordered on the day of hospital discharge … hospital practice: factors associated with turnover, outcomes, and patient safety. … October 1, 2008
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Hospitals
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psnet.ahrq.gov/issue/building-resilient-patient-safety-culture-large-healthcare-organizations-approach
November 03, 2015 - hospital practice: factors associated with turnover, outcomes, and patient safety. … September 24, 2016
El Camino Hospital: using health information technology to promote … March 6, 2024
Hospital staff reports of coworker positive and unprofessional behaviours … across eight hospitals: who reports what about whom? … March 10, 2021
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Hospitals
Ambulatory
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psnet.ahrq.gov/issue/prescription-opioid-analgesics-commonly-unused-after-surgery-systematic-review
March 30, 2022 - A large number of deaths in the United States have been caused by opioid misuse. … multistate hospital network--13 academic medical centers, April-June 2020. … November 16, 2022
Adverse events in hospitalized pediatric patients. … April 4, 2018
Predictors of in-hospital postoperative opioid overdose after major elective … December 2, 2015
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Hospitals
Health