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psnet.ahrq.gov/issue/double-checking-medicines-defence-against-error-or-contributory-factor
January 31, 2024 - An analysis of staff and patient survey data and routinely collected outcomes. … 2018
A qualitative study of patient involvement in medicines management after hospital discharge … June 8, 2011
Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental … February 14, 2011
Description of inpatient medication management using cognitive work
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psnet.ahrq.gov/issue/improving-medication-safety-accurate-preadmission-medication-lists-and-postdischarge
June 26, 2019 - This likely was the major contributor to the reduction of observed inpatient medication errors from … June 26, 2019
A toolkit to disseminate best practices in inpatient medication reconciliation … May 31, 2023
Incidence and trends of sepsis in US hospitals using clinical vs claims data … Effect of a pharmacist intervention on clinically important medication errors after hospital discharge
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psnet.ahrq.gov/issue/if-only-failed-missed-and-absent-error-recovery-opportunities-medication-errors
July 15, 2009 - June 15, 2011
Defining near misses: towards a sharpened definition based on empirical data … by face-to-face feedback to prescribers on adverse drug events recognition and prevention in older inpatients … Effect of a pharmacist intervention on clinically important medication errors after hospital discharge … June 20, 2012
Clinical and safety impact of an inpatient pharmacist-directed anticoagulation … pharmacists, physicians and nurse practitioners: a qualitative investigation of working relationships in the inpatient
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psnet.ahrq.gov/issue/development-instrument-measure-unintended-consequences-ehrs
June 22, 2011 - This commentary describes how existing data was used to develop a tool to measure unintended consequences … March 29, 2023
Assessment of the use of patient vital sign data for preventing misidentification … electronic medication systems in reducing medication error rates and associated harm among hospital inpatients … April 15, 2020
Pending studies at hospital discharge: a pre-post analysis of an electronic … medical record tool to improve communication at hospital discharge.
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psnet.ahrq.gov/issue/clinically-inconsequential-alerts-characteristics-opioid-drug-alerts-and-their-utility
May 18, 2022 - impact of evidence-based design strategies on patient safety, healing, and satisfaction in an adult inpatient … March 13, 2019
Incidence and predictors of opioid prescription at discharge after traumatic … August 15, 2018
Usage and accuracy of medication data from nationwide health information … March 13, 2018
Opioid abuse and poisoning: trends in inpatient and emergency department
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psnet.ahrq.gov/issue/safety-culture-and-mortality-after-acute-myocardial-infarction-study-medicare-beneficiaries
September 13, 2023 - In this observational cohort study, researchers analyzed data from 19,357 discharges for acute myocardial … infarction (AMI) across 171 hospitals and associated data from AHRQ Hospital Survey on Patient Safety … May 15, 2024
The safety of inpatient health care. … Association of changing hospital readmission rates with mortality rates after hospital discharge
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psnet.ahrq.gov/node/49706/psn-pdf
January 01, 2015 - However, after the second discharge the inpatient pharmacist
was contacted by the pharmacist at the … The outpatient pharmacist informed
the inpatient pharmacist that a prescription for vancomycin oral … Where
possible, obtain prior authorization before discharge and engage discharge planners or the pharmacist … Limited data characterize the best treatment course for patients with multiple recurrences, but
stool … discharge planning and pharmacy to help identify resources to meet those needs.
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psnet.ahrq.gov/issue/patterns-potential-opioid-misuse-and-subsequent-adverse-outcomes-medicare-2008-2012
June 30, 2021 - This study used Medicare data to examine the relationship between potential opioid misuse and opioid … These results provide insight on how best to use data from prescription drug monitoring programs , which … September 29, 2017
Adverse inpatient outcomes during the transition to a new electronic … September 1, 2021
Early death after discharge from emergency departments: analysis of … national US insurance claims data.
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psnet.ahrq.gov/issue/using-failure-mode-and-effects-analysis-increase-patient-safety-cancer-chemotherapy
August 18, 2021 - respond to errors in their personal health records: mixed methods analysis of cross-sectional survey data … July 27, 2022
Inpatient telemedicine and new models of care during COVID-19: hospital … September 15, 2021
Longitudinal medication reconciliation at hospital admission, discharge … and post-discharge.
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psnet.ahrq.gov/issue/reducing-anticoagulant-medication-adverse-events-and-avoidable-patient-harm
May 19, 2021 - November 4, 2015
Medical large language models are vulnerable to data-poisoning attacks … Effect of medication reconciliation on patient reported potential adverse events after hospital discharge … September 8, 2021
Drug-drug interactions and prescription appropriateness at hospital discharge … December 30, 2014
Clinical and safety impact of an inpatient pharmacist-directed anticoagulation
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psnet.ahrq.gov/issue/observational-study-conformity-yet-another-medical-learning-environment-conformity-preceptors
June 19, 2019 - Can routinely collected data be repurposed to predict avoidable patient harm? … January 29, 2020
Older veterans and emergency department discharge information. … October 10, 2012
Older patients' understanding of emergency department discharge information … May 7, 2014
Perspective
What Have We Learned About Safe Inpatient
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psnet.ahrq.gov/issue/alarming-reality-medication-error-patient-case-and-review-pennsylvania-and-national-data
June 28, 2017 - The alarming reality of medication error: a patient case and review of Pennsylvania and national data … The alarming reality of medication error: a patient case and review of Pennsylvania and National data … The alarming reality of medication error: a patient case and review of Pennsylvania and National data … December 3, 2014
A toolkit to disseminate best practices in inpatient medication reconciliation … September 9, 2013
Quality improvement through implementation of discharge order reconciliation
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psnet.ahrq.gov/node/49417/psn-pdf
October 01, 2003 - answered.(9) One is the impact of the
"purposeful discontinuity" that the model introduces between inpatient … three areas: clear delineation of roles and
responsibilities, better methods for transmitting verbal data … quantitative HIV PCR
may have facilitated this error by exposing another hole in the Swiss Cheese of our data … The incidence and severity of adverse
events affecting patients after discharge from the hospital. … Using a computerized sign-out program to
improve continuity of inpatient care and prevent adverse events
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psnet.ahrq.gov/web-mm/lost-black-hole
December 01, 2005 - three areas: clear delineation of roles and responsibilities, better methods for transmitting verbal data … PCP.( 12 ) Practically, though, saying that both the hospitalist and the PCP are responsible after discharge … quantitative HIV PCR may have facilitated this error by exposing another hole in the Swiss Cheese of our data … The incidence and severity of adverse events affecting patients after discharge from the hospital. … Using a computerized sign-out program to improve continuity of inpatient care and prevent adverse events
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psnet.ahrq.gov/issue/medication-reconciliation-meets-its-match
May 01, 2017 - May 3, 2022
Eliminating CAUTI: Interim Data Report: A National Patient Safety Imperative … June 27, 2016
Re-Engineered Discharge (RED) Toolkit. … December 27, 2014
Inpatient Computerized Provider Order Entry: Findings from the AHRQ … May 7, 2014
Eliminating CAUTI: Interim Data Report: A National Patient Safety Imperative
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psnet.ahrq.gov/issue/systematic-review-types-and-causes-prescribing-errors-generated-using-computerized-provider
July 02, 2019 - clinicians place orders for tests, labs, and medications electronically, has grown rapidly in both inpatient … Although research has shown that implementation of CPOE can reduce prescribing errors in both inpatient … 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
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psnet.ahrq.gov/issue/effect-pharmacy-based-centralized-intravenous-admixture-service-prevalence-medication-errors
December 01, 2021 - In this before-and-after study, IAPE data were collected to evaluate the safety of a pharmacy-based … The effect of a transitional pharmaceutical care program on the occurrence of ADEs after discharge … October 13, 2021
Medication-related hospital readmissions within 30 days of discharge … by face-to-face feedback to prescribers on adverse drug events recognition and prevention in older inpatients … June 1, 2022
Medication-related interventions delivered both in hospital and following discharge
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psnet.ahrq.gov/issue/neurologic-patient-safety-depth-study-malpractice-claims
November 11, 2015 - Related Resources From the Same Author(s)
Organization and representation of patient safety data … May 15, 2024
The safety of inpatient health care. … Missed diagnosis of cancer in primary care: insights from malpractice claims data … August 7, 2019
Learning from lawsuits: using malpractice claims data to develop care … June 22, 2009
Risk of medication errors at hospital discharge and barriers to problem
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psnet.ahrq.gov/issue/what-can-hospitalized-patients-tell-us-about-adverse-events-learning-patient-reported
June 29, 2011 - In this prospective study, investigators used post-discharge interviews and medical record review to … The authors enrolled 228 patients hospitalized on an inpatient medical service and discovered that 8% … June 29, 2011
Do medical inpatients who report poor service quality experience more adverse … September 23, 2020
Use of administrative data to find substandard care: validation of … contextualise care more often when they discover patient context by asking: meta-analysis of three primary data
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psnet.ahrq.gov/node/867986/psn-pdf
March 24, 2025 - If they
are in an emergency department, an inpatient unit, or, of course, a behavioral health unit, … Let’s start with the emergency department and inpatient settings. … When people
present to care at an emergency department or get admitted to an inpatient facility, they … The health system I work in, as
well as other organizations, have published data showing that when you … .6 The closer to discharge the better, because the days after discharge are the most vulnerable
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