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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/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/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/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/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/developing-culture-collaboration-operating-room-more-effective-communication
June 27, 2018 - May 18, 2022
Engaging patients in the use of real-time electronic clinical data to improve … The effect of a transitional pharmaceutical care program on the occurrence of ADEs after discharge … January 25, 2023
The safety of inpatient health care. … April 14, 2021
SAFER Care: improving caregiver comprehension of discharge instructions … November 11, 2020
Variability in collection and use of race/ethnicity and language data
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psnet.ahrq.gov/periodic-issue/periodic-issue-311
September 29, 2021 - Discharge from the hospital represents a vulnerable time for patients. … compared wrong blood in tube (WBIT) errors in 9 countries across three settings: emergency department, inpatient … patient identification (ePPID) significantly reduced WBIT errors in the emergency department, but not in inpatient … The commentary discusses the limitations of prescription drug monitoring program (PDMP) data for patients … hospital; however, he was misdiagnosed with Staphylococcal meningitis, and it was not until his third inpatient
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psnet.ahrq.gov/node/41100/psn-pdf
February 01, 2012 - Healthcare Research and Quality's Patient Safety Indicators (PSIs) are widely used to
screen administrative data … for evidence of adverse events in adult inpatients.
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psnet.ahrq.gov/issue/medication-safety-moving-illusion-reality
July 29, 2020 - Related Resources From the Same Author(s)
The tradeoffs between safety and alert fatigue: data … October 4, 2023
Engaging patients in the use of real-time electronic clinical data to … November 7, 2018
The safety of inpatient health care. … January 25, 2023
Creating a better discharge summary: improvement in quality and timeliness … using an electronic discharge summary.
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psnet.ahrq.gov/web-mm/delay-treatment-failure-contact-patient-leads-significant-complications
February 01, 2004 - inform the patient of the result.( 5 ) The same issues afflict handling of abnormal test results for inpatients … "( 10 ) Data provide some support for giving patients access to their test results.( 11 ) The literature … There are few data on the incidence of malpractice cases related to inadequate patient notification and … The ED discharge instructions given to Rory Staunton's parents contained a line for pending tests and … March 1, 2015
Last orders: follow-up of tests ordered on the day of hospital discharge
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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/clinical-pharmacist-led-transitions-care-program-veterans-two-planned-care-transitions
December 23, 2011 - Citation
Related Resources From the Same Author(s)
Developing indicators of inpatient … adverse drug events through nonlinear analysis using administrative data. … WebM&M Cases
Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge … Understanding hazards for adverse drug events among older adults after hospital discharge … July 21, 2021
Community-acquired and hospital-acquired medication harm among older inpatients
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psnet.ahrq.gov/issue/variation-electronic-test-results-management-and-its-implications-patient-safety-multisite
June 02, 2021 - electronic medication systems in reducing medication error rates and associated harm among hospital inpatients … between double-checking and medication administration errors: a direct observational study of paediatric inpatients … January 18, 2023
Clinical data sharing improves quality measurement and patient safety … October 5, 2022
The tradeoffs between safety and alert fatigue: data from a national … The effect of a clinical decision support for pending laboratory results at emergency department discharge
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psnet.ahrq.gov/issue/evaluating-patient-identification-practices-during-intrahospital-transfers-human-factors
August 18, 2021 - reduce duration and variability in delays to identification of serious injury after falls in hospital inpatients … Descriptive analysis of patient misidentification from incident report system data … October 20, 2021
Longitudinal medication reconciliation at hospital admission, discharge … and post-discharge. … "It's like two worlds apart": an analysis of vulnerable patient handover practices at discharge
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psnet.ahrq.gov/issue/content-analysis-patient-safety-incident-reports-older-adult-patient-transfers-handovers-and
December 14, 2022 - November 24, 2021
How do hospital inpatients conceptualise patient safety? … 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/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/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/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-do-healthcare-staff-think-about-quality-and-safety-care-provided-children-and-young
February 07, 2024 - May 25, 2022
Patients' reports of adverse events: a data linkage study of Australian … May 29, 2024
Medication safety gaps in English pediatric inpatient units: an exploration … March 6, 2024
Parents' understanding of medication at discharge and potential harm in … September 6, 2023
Caregiver and clinician perspectives on discharge medication counseling
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psnet.ahrq.gov/web-mm/continuity-errors-resident-clinic
October 02, 2019 - chance that their patients received pap smears in the resident clinic approached zero (unpublished data … and outpatient time (e.g., 4 inpatient weeks followed by 1 outpatient week or 6 inpatient weeks followed … safety, the learning environment, and resident–patient relationships, but no actual patient outcomes data … Frequent measurement and sharing of data are first steps to achieving a culture of shared responsibility … WebM&M Cases
Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge