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psnet.ahrq.gov/issue/health-information-technology-and-its-effects-hospital-costs-outcomes-and-patient-safety
January 29, 2018 - June 27, 2018
Re-Engineered Discharge (RED) Toolkit. … June 16, 2014
Inpatient Computerized Provider Order Entry: Findings from the AHRQ Health … May 7, 2014
Eliminating CAUTI: Interim Data Report: A National Patient Safety Imperative … October 18, 2011
Association between hospital-reported Leapfrog Safe Practices scores and inpatient
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psnet.ahrq.gov/issue/measurement-patient-safety-systematic-review-reliability-and-validity-adverse-event-detection
November 16, 2016 - Consistency of event identification was adequate, but data are lacking regarding validity of medical … clinical handover between intensive care unit and general ward professionals at intensive care unit discharge … Organizational culture: an important context for addressing and improving hospital to community patient discharge … April 15, 2016
Interventions to reduce nurses' medication administration errors in inpatient
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psnet.ahrq.gov/issue/nurse-staffing-levels-and-quality-care-hospitals
June 25, 2010 - Investigators examined administrative data encompassing more than 6 million medical and surgical hospital … March 3, 2011
Nurse staffing and inpatient hospital mortality. … June 29, 2011
Systematic review: the evidence that publishing patient care performance data … February 3, 2016
Association of registered nurse and nursing support staffing with 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/node/33771/psn-pdf
August 22, 2014 - patients discharged from a tertiary
academic hospital, 19% had an adverse event within 3 weeks of discharge … , and 30% of these resulted in a
nonpermanent disability or worse.(5) A review of 14,700 discharge records … Extrapolating from these data, an estimated 75,000 hospitalizations per
year are due to preventable … There is no need to wait for additional data to get started on error reduction in
the outpatient setting … The incidence and severity of adverse events
affecting patients after discharge from the hospital.
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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/national-cost-adverse-drug-events-resulting-inappropriate-medication-related-alert-overrides
July 02, 2019 - Extrapolating medication order data from a random sample of patients at a single academic medical center … over a 1-year period, researchers estimate that in 2014 there were 29.7 million adult inpatient discharges … From the Same Author(s)
Medication-related clinical decision support alert overrides in inpatients … 2013
The frequency of inappropriate nonformulary medication alert overrides in the inpatient … July 23, 2018
Impact of an inpatient electronic prescribing system on prescribing error
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psnet.ahrq.gov/issue/diagnostic-errors-orthopedic-surgery-evaluation-resident-documentation-neurovascular
December 31, 2014 - November 16, 2022
Medical large language models are vulnerable to data-poisoning attacks … Design and implementation of an automated email notification system for results of tests pending at discharge … 2014
Impact of an automated email notification system for results of tests pending at discharge … February 13, 2019
Safety of overlapping inpatient orthopaedic surgery: a multicenter
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psnet.ahrq.gov/issue/do-trainees-feel-they-belong-team
August 16, 2017 - September 18, 2019
Danger in discharge summaries: abbreviations create confusion for … 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 … January 27, 2021
Separating residents' inpatient and outpatient responsibilities: improving
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psnet.ahrq.gov/issue/automatic-detection-omissions-medication-lists
December 31, 2014 - December 31, 2014
A toolkit to disseminate best practices in inpatient medication reconciliation … February 23, 2018
Improving the discharge process by embedding a discharge facilitator … reporting: lessons learned from machine learning analysis of NHS England staff survey and incident data
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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/medical-adverse-events-us-2018-mortality-data
December 21, 2022 - Study
Medical adverse events in the US 2018 mortality data. … Medical adverse events in the US 2018 mortality data. … Medical adverse events in the US 2018 mortality data. … the Same Author(s)
A recent two-fold increase in medical adverse event deaths among US inpatients … Incidence and variables associated with inconsistencies in opioid prescribing at hospital discharge
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psnet.ahrq.gov/issue/patient-safety-plastic-surgery-identifying-areas-quality-improvement-efforts
November 01, 2017 - Related Resources From the Same Author(s)
Opioid abuse and poisoning: trends in inpatient … The TRANSFORM patient safety project: a microsystem approach to improving outcomes on inpatient … and 6 years of Alabama data reveal. … February 10, 2012
Office surgery incidents: what seven years of Florida data show us. … July 10, 2008
Promoting a culture of patient safety: a review of the Florida moratoria data
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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/issue/assessment-safety-enhancement-hospital-medication-reconciliation-process-elderly-patients
August 04, 2021 - medications with indications, improved the accuracy of the medication reconciliation process for elderly inpatients … August 4, 2021
Potential benefit of electronic pharmacy claims data to prevent medication … history errors and resultant inpatient order errors. … Project (NAP5) on accidental awareness during general anaesthesia: protocol, methods, and analysis of data … February 15, 2011
Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental
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psnet.ahrq.gov/issue/harmed-patient-alliance
October 31, 2018 - Risks to Medication Delivery Using Ambulatory Infusion Pumps – Design and Usability in Inpatient … September 6, 2024
Discharge from Mental Health Care: Making it Safe and Patient-centred … December 20, 2023
View More
Related Resources
Annual Speak Up Data
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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/node/49710/psn-pdf
May 01, 2014 - A medication
reconciliation process in which the discharge summary and discharge medication list are … Such an approach would include an
inpatient pharmacist connecting with the patient and the community … Medication reconciliation: a necessity in promoting a
safe hospital discharge. … Decreasing medication discrepancies between outpatient and inpatient care
through the use of computerized … pharmacy data.
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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/overall-performance-drug-drug-interaction-clinical-decision-support-system-quantitative
August 10, 2022 - Based on an analysis of DDI alerts and survey data regarding physician experience using the DDI module … by face-to-face feedback to prescribers on adverse drug events recognition and prevention in older inpatients … of a computer-assisted tool with automated electronic integration of population-based community drug data … March 2, 2011
Drug-drug interactions and prescription appropriateness at hospital discharge … events by application of a probabilistic, machine-learning based clinical decision support system in an inpatient