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psnet.ahrq.gov/issue/reliability-assessment-preventable-adverse-drug-events-daily-clinical-practice
March 04, 2011 - Although most inpatient adverse drug events are considered preventable , this study found that independent … December 29, 2014
Communicating medication changes to community pharmacy post-discharge … June 23, 2010
Potential utility of data-mining algorithms for early detection of potentially
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psnet.ahrq.gov/issue/veterans-health-care-veterans-health-administration-processes-responding-reported-adverse
August 15, 2012 - January 8, 2014
VA Health Care: VA Uses Medical Injury Tort Claims Data to Assess Veterans … ’ Care, but Should Take Action to Ensure That These Data Are Complete. … February 15, 2017
Trends in Potentially Preventable Inpatient Hospital Admissions and … June 13, 2012
Managing Patients' Medicines after Discharge from Hospital.
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psnet.ahrq.gov/print/pdf/node/74277
January 01, 2021 - multifaceted, system-level approach that spans all areas of health
care delivery, such as primary, specialty, inpatient … multifaceted, system-level approach that spans all areas of health
care delivery, such as primary, specialty, inpatient … Medication errors are prevalent in inpatient care. … Adverse drug events after hospital discharge in older adults: types, severity, and involvement of Beers … commentary suggests strategies for improving prescribing safety, including linking pharmacy and
laboratory data
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psnet.ahrq.gov/issue/adverse-drug-events-and-medication-problems-hospital-home-patients
December 16, 2020 - In "Hospital at Home" (HaH) programs, patients receive inpatient medical treatment such as intravenous … June 13, 2011
Learning from lawsuits: using malpractice claims data to develop care transitions … home visits for middle-aged and older adults receiving skilled home healthcare services after hospital discharge
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psnet.ahrq.gov/issue/unintended-adverse-consequences-introducing-electronic-health-records-residential-aged-care
March 24, 2019 - extensive body of literature documents the unintended consequences of information technology in the inpatient … July 13, 2022
Data consistency in a voluntary medical incident reporting system. … September 28, 2016
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Related Resources
Danger in discharge
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psnet.ahrq.gov/issue/medication-administration-errors-older-people-long-term-residential-care
June 26, 2019 - Data from a barcode medication administration (BCMA) system revealed that over a 3-month period, half … June 26, 2019
Assessment of requests for medication-related follow-up after hospital discharge … by face-to-face feedback to prescribers on adverse drug events recognition and prevention in older inpatients … 2018
An observational study of medication administration errors in old-age psychiatric inpatients
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psnet.ahrq.gov/issue/using-clinical-decision-support-improve-medication-reconciliation
December 10, 2014 - Resources From the Same Author(s)
Alarm management: first things first: using reliable data … January 7, 2015
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/49750/psn-pdf
January 01, 2016 - establish a relationship with the outpatient physician who will re-assume the patient's
care after discharge … and
associated tools to meet information and patient care needs depends on accurate, timely input of data … The inpatient provider could then assess the
patient, review the pending orders, and initiate them when … Instituting daily multidisciplinary rounds to discuss new admissions, discharge readiness, and
anticipated … discharge dates, as well as potential transfers and planned admissions.
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psnet.ahrq.gov/issue/medication-errors-related-computerized-provider-order-entry-systems-hospitals-and-how-they
April 07, 2021 - respond to errors in their personal health records: mixed methods analysis of cross-sectional survey data … April 10, 2024
Longitudinal medication reconciliation at hospital admission, discharge … and post-discharge. … August 26, 2020
The tradeoffs between safety and alert fatigue: data from a national … electronic medication systems in reducing medication error rates and associated harm among hospital inpatients
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psnet.ahrq.gov/issue/clinical-evaluation-ade-scorecards-decision-support-tool-adverse-drug-event-analysis-and
December 31, 2014 - This study developed scorecards that screen real-time data with complex automated rules to identify possible … July 21, 2021
Learning from lawsuits: using malpractice claims data to develop care transitions … February 4, 2015
French national survey of inpatient adverse events prospectively assessed … March 23, 2011
Medication details documented on hospital discharge: cross-sectional observational
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psnet.ahrq.gov/issue/who-applies-intervention-influence-cultural-attributes-quality-improvement-collaborative
January 22, 2016 - This analysis of data from the Keystone ICU project found that sites with a higher perceived safety climate … Related Resources From the Same Author(s)
Safety culture in cardiac surgical teams: data … The TRANSFORM patient safety project: a microsystem approach to improving outcomes on inpatient … reliability of verbal communication between primary care physicians and pediatric hospitalists at hospital discharge
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psnet.ahrq.gov/issue/physician-spending-and-subsequent-risk-malpractice-claims-observational-study
May 01, 2015 - This secondary data analysis examined prospectively whether physicians who performed more cesarean deliveries … September 29, 2017
Early death after discharge from emergency departments: analysis of … national US insurance claims data. … July 10, 2017
Adverse inpatient outcomes during the transition to a new electronic health
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psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure
December 23, 2020 - Even in 2008, most practices in the United States continue to use paper-based discharge communication … Data clearly show that they want this access, whether they are insured or uninsured ( 13 ), and this … best—including the patient, their family, and their community—is much greater than what can be achieved by an inpatient … the care process and should be implemented as a part of any health information technology project, inpatient … December 1, 2021
Interunit handoffs from emergency department to inpatient care: a cross-sectional
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psnet.ahrq.gov/issue/overview-intravenous-related-medication-administration-errors-reported-medmarxr-national
April 14, 2021 - The authors analyzed 5 years' worth of Medmarx data and found three trends in intravenous drug administration … 2019
Prevalence and nature of medication errors and medication-related harm following discharge … Development of the Leapfrog Group's bar code medication administration standard to address hospital inpatient
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psnet.ahrq.gov/web-mm/room-without-orders
September 01, 2011 - establish a relationship with the outpatient physician who will re-assume the patient's care after discharge … and associated tools to meet information and patient care needs depends on accurate, timely input of data … Instituting daily multidisciplinary rounds to discuss new admissions, discharge readiness, and anticipated … discharge dates, as well as potential transfers and planned admissions. … WebM&M Cases
Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge
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psnet.ahrq.gov/issue/business-intelligence-dashboards-patient-safety-and-quality-narrative-literature-review
February 09, 2022 - Dashboards provide a way to display patient safety data (e.g., medication safety) in real time. … An analysis of the structure and content of dashboards used to monitor patient safety in the inpatient … August 7, 2013
The efficacy of computer-enabled discharge communication interventions
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psnet.ahrq.gov/issue/child-health-pso-10-years-emerging-learning-network
July 28, 2021 - Patient safety organizations (PSOs) collect and analyze protected safety incident data from across the … August 4, 2021
Quantifying discharge medication reconciliation errors at 2 pediatric … Development of the Leapfrog Group's bar code medication administration standard to address hospital inpatient … January 12, 2012
Evaluation of an anonymous system to report medical errors in pediatric inpatients
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psnet.ahrq.gov/node/49675/psn-pdf
February 01, 2013 - hospital EDs to disclose and discuss the results of children's
laboratory tests with their parents before discharge … 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
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psnet.ahrq.gov/issue/analysis-errors-dictated-clinical-documents-assisted-speech-recognition-software-and
July 06, 2022 - accuracy of speech recognition software in a sample of notes (progress notes, operative notes, and discharge … December 2, 2020
Clinical data sharing improves quality measurement and patient safety … March 14, 2018
Efficiency and interpretability of text paging communication for medical inpatients … 2017
Impact of an automated email notification system for results of tests pending at discharge
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psnet.ahrq.gov/issue/pediatric-antidepressant-medication-errors-national-error-reporting-database
September 21, 2008 - This analysis of MEDMARX data found that harmful errors involving antidepressants most commonly occurred … April 16, 2018
Toward understanding errors in inpatient psychiatry: a qualitative inquiry … December 2, 2014
Adverse drug events after hospital discharge in older adults: types,