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psnet.ahrq.gov/periodic-issue/periodic-issue-296
June 30, 2021 - This retrospective study, based on patient discharge data from three Irish hospitals, characterized nursing-sensitive … Results indicate that 16% of patients experienced at least one nurse-sensitive adverse event during their inpatient … This retrospective study, based on patient discharge data from three Irish hospitals, characterized nursing-sensitive … Results indicate that 16% of patients experienced at least one nurse-sensitive adverse event during their inpatient … Decreasing inpatient falls requires improvements in both processes of care and the care environment.
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psnet.ahrq.gov/periodic-issue/periodic-issue-379
February 01, 2023 - care and discharge plan. … care and discharge plan. … Study
Nursing student errors and near misses: three years of data. … Maternal and Infant Health Inequality: New Evidence from Linked Administrative Data … Magazine Article
Pump up the volume: how to prioritize events and analyze error data
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psnet.ahrq.gov/web-mm/postdischarge-follow-phone-call
May 19, 2021 - outpatient visits.( 5 ) Hospital-based transitional care interventions aim to smooth the transition from the inpatient … Unfortunately, most of the data evaluating postdischarge calls as an independent intervention are of … Little data exist to guide provider selection. … Track call outcomes to help inpatient providers learn from issues addressed in the call. … Phone calls should feedback the most common preventable postdischarge issues back to the inpatient physicians
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psnet.ahrq.gov/issue/direct-oral-anticoagulant-related-medication-incidents-and-pharmacists-interventions-hospital
January 12, 2022 - January 12, 2022
Assessment of requests for medication-related follow-up after hospital discharge … October 14, 2020
The tradeoffs between safety and alert fatigue: data from a national … 24, 2021
Medication-related interventions delivered both in hospital and following discharge … Resources
Prevented harm and cost avoidance with pharmacist intervention while utilizing a discharge … December 30, 2014
Clinical and safety impact of an inpatient pharmacist-directed anticoagulation
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psnet.ahrq.gov/issue/tipping-point-relationship-between-volume-and-patient-harm
September 10, 2014 - A retrospective study of electronic health record data. … processing approach to identify diagnostic errors and analysis of safety learning system case review data … November 8, 2013
Improving the discharge process by embedding a discharge facilitator … January 26, 2011
The association between transfer of emergency department boarders to inpatient
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psnet.ahrq.gov/issue/intensive-care-unit-critical-incident-analysis-objective-tool-select-content-simulation
June 28, 2023 - This process of integrating critical incident data with trainee self-assessment can be generalized to … June 28, 2023
Safety of surgical telehealth in the outpatient and inpatient setting. … June 22, 2009
Medical large language models are vulnerable to data-poisoning attacks. … January 17, 2024
Hospital Differences in Adult Inpatient Stays with Healthcare-Associated … April 20, 2022
Patient harm and institutional avoidability of out-of-hours discharge
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psnet.ahrq.gov/issue/medication-administration-errors-and-pediatric-population-systematic-search-literature
September 16, 2015 - This review explores medication administration errors in the pediatric inpatient population. … May 17, 2023
Development and sustainability of an inpatient-to-outpatient discharge handoff … January 21, 2009
Cost-effective enhancement of claims data to improve comparisons of … reduce duration and variability in delays to identification of serious injury after falls in hospital inpatients … 2022
Performance variability in perioperative sentinel events: report on a nationwide data
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psnet.ahrq.gov/issue/ensuring-medication-reconciliation
December 19, 2012 - describe the team-based process they used to improve medication management at the admission, transfer, and discharge … January 10, 2018
Alarm management: first things first: using reliable data to eliminate … November 21, 2016
Assessment of patient retention of inpatient care information post-hospitalization … April 29, 2018
Five hospitals release data on inspections.
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psnet.ahrq.gov/issue/patterns-nurse-physician-communication-and-agreement-plan-care
December 21, 2014 - Nurses and physicians on an inpatient unit did not communicate with each other regularly, resulting in … September 30, 2015
Creating a better discharge summary: improvement in quality and timeliness … using an electronic discharge summary. … May 6, 2009
Comparison of traditional trigger tool to data warehouse based screening
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psnet.ahrq.gov/node/73389/psn-pdf
June 16, 2021 - This retrospective study, based on
patient discharge data from three Irish hospitals, characterized … indicate that 16% of patients experienced at least one nurse-sensitive adverse
event during their inpatient
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psnet.ahrq.gov/issue/classification-antecedents-towards-safety-use-health-information-technology-systematic-review
October 12, 2022 - January 19, 2022
Raising the awareness of inpatient nursing staff about medication errors … 24, 2018
Automatable algorithms to identify nonmedical opioid use using electronic data … August 24, 2015
The efficacy of computer-enabled discharge communication interventions … Implementation of medication error reporting through Med Safe Tool: the clinical pharmacists and the inpatient
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psnet.ahrq.gov/issue/national-trends-safety-performance-electronic-health-record-systems-childrens-hospitals
July 29, 2020 - Related Resources From the Same Author(s)
The tradeoffs between safety and alert fatigue: data … June 17, 2020
Inpatient EHR user experience and hospital EHR safety performance. … August 14, 2018
A trigger tool to detect harm in pediatric inpatient settings. … December 21, 2018
Using an inpatient portal to engage families in pediatric hospital … , 2018
Improving communication with primary care physicians at the time of hospital discharge
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psnet.ahrq.gov/issue/educating-medical-trainees-medication-reconciliation-systematic-review
October 16, 2019 - of a computer-assisted tool with automated electronic integration of population-based community drug data … Incidence and variables associated with inconsistencies in opioid prescribing at hospital discharge … May 5, 2021
Failure to follow medication changes made at hospital discharge is associated … December 3, 2018
Usage and accuracy of medication data from nationwide health information … View More
Related Resources
Evaluation of interventions to improve inpatient
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psnet.ahrq.gov/node/73643/psn-pdf
August 01, 2022 - llipsitz@bidmc.harvard.edu
Date First Implemented
2013-08-28
Problem Addressed
Transitions from inpatient … address communication gaps between the hospital and the
SNF providers when patients transition from the inpatient … Results
Data analysis for the implementation of ECHO-CT was conducted at the level of the SNF as well … effective and not overly time- or work-
intensive.2 Finally, the ECHO-CT research team was able to use data … Once program implementation has begun and weekly videoconferences are underway, data collection
should
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psnet.ahrq.gov/periodic-issue/periodic-issue-456
September 25, 2024 - This study used hospital discharge data from nearly 2.1 million discharges for Medicaid and privately … In this study, researchers interviewed 12 former inpatient mental health service users in the United … Kingdom about their perspectives on psychological safety in inpatient mental health settings. … This study used hospital discharge data from nearly 2.1 million discharges for Medicaid and privately … on his left elbow, where wood chips were noted on exam and x-ray but were not fully removed before discharge
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psnet.ahrq.gov/issue/medication-errors-community-pharmacies-need-commitment-transparency-and-research
June 17, 2020 - Medication errors are common in inpatient and ambulatory environments. … The authors call for community pharmacy corporations to encourage the discussion and data sharing needed … December 22, 2021
Longitudinal medication reconciliation at hospital admission, discharge … and post-discharge.
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psnet.ahrq.gov/issue/electronic-health-records-communication-and-data-sharing-challenges-and-opportunities
October 13, 2018 - Study
Electronic health records, communication, and data sharing: challenges and … Electronic health records, communication, and data sharing: challenges and opportunities for improving … team of social scientists and clinicians conducted an ethnographic study of physicians on academic inpatient … Additionally, the electronic health record led to data overload and data fragmentation. … Nets to Reduce Missed and Delayed Diagnoses of Cancer
July 31, 2023
Danger in discharge
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psnet.ahrq.gov/web-mm/direct-oral-anticoagulants-are-high-risk-medications-potentially-complex-dosing
August 21, 2005 - an inpatient stay, new challenges arise as they resume responsibility for obtaining and managing their … insert 20
b Data adopted from dabigatran package insert 21
c Data adopted from edoxaban package … If a patient being discharged has already started taking the DOAC as an inpatient, but a starter pack … “Pharmacists implementing transitions of care in inpatient, ambulatory and community practice settings … Resources From the Same Author(s)
WebM&M Cases
Impatient Inpatient
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psnet.ahrq.gov/issue/emergency-department-contribution-prescription-opioid-epidemic
June 21, 2016 - This retrospective study used data from the Medical Expenditure Panel Survey from 1996 to 2012 and found … June 30, 2021
Incidence and predictors of opioid prescription at discharge after traumatic … March 13, 2018
Opioid abuse and poisoning: trends in inpatient and emergency department … August 30, 2017
Early death after discharge from emergency departments: analysis of national … US insurance claims data.
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psnet.ahrq.gov/issue/using-medicolegal-data-support-safe-medical-care-contributing-factor-coding-framework
April 03, 2024 - Commentary
Using medicolegal data to support safe medical care: a contributing factor … Using medicolegal data to support safe medical care: A contributing factor coding framework. … Using medicolegal data to support safe medical care: A contributing factor coding framework. … July 19, 2023
Improving discharge safety in a pediatric emergency department. … November 1, 2017
Efficiency and interpretability of text paging communication for medical inpatients