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psnet.ahrq.gov/issue/prevention-adverse-drug-events-hospitals
July 23, 2014 - November 23, 2024
Use of administrative data to find substandard care: validation of … June 16, 2010
Hospital discharge and readmission. … December 21, 2014
Effect of patient- and medication-related factors on inpatient medication
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psnet.ahrq.gov/issue/content-analysis-patient-complaints
January 18, 2023 - May 20, 2020
The impact of checklists on inpatient safety outcomes: a systematic review … September 29, 2021
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Related Resources
Integrating incident data … January 4, 2015
Hospital readmission and parent perceptions of their child's hospital discharge
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psnet.ahrq.gov/web-mm/it-safe-be-direct
September 30, 2015 - Finally, factors such as inadequate systems for triaging and observing patients awaiting an inpatient … systematic review revealed the frequent failure of information transfer that occurs during hospital discharge … For the hospitalist, lack of access to outpatient clinic notes, labs, and other significant data impedes … June 11, 2010
Creating a better discharge summary: improvement in quality and timeliness … using an electronic discharge summary.
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psnet.ahrq.gov/issue/rates-surgical-consultations-after-emergency-department-admission-black-and-white-medicare
February 10, 2021 - This large, retrospective cohort study using Medicare data identified disparities between Black and … impact of evidence-based design strategies on patient safety, healing, and satisfaction in an adult inpatient … The effect of a transitional pharmaceutical care program on the occurrence of ADEs after discharge … misdiagnosis in adult emergency department patients: a look-forward analysis with administrative claims data
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psnet.ahrq.gov/node/74022/psn-pdf
March 01, 2021 - transition process are caught and corrected before the medication is dispensed.8 For example, in
the discharge … process, the inpatient providers may have an incomplete history of the patient’s existing
prescriptions … In addition, medications that may have been appropriate
during the inpatient stay, but inappropriate … prescribers can
support community pharmacists in the prevention of errors.10,11 Interoperability between data … Impact of community pharmacist-
performed post-discharge medication reviews in transitions of care.
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psnet.ahrq.gov/issue/adapting-rapid-assessment-procedures-implementation-research-using-team-based-approach
November 09, 2022 - a multidisciplinary evaluation team, building trust with the sites, engaging sites in participatory data … collection, rapid team analysis of data sources, and validating findings with the sites. … April 26, 2023
Engaging patients in the use of real-time electronic clinical data … An analysis of the structure and content of dashboards used to monitor patient safety in the inpatient … May 5, 2021
Clinical predictors for unsafe direct discharge home patients from intensive
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psnet.ahrq.gov/issue/prevalence-and-nature-medication-administration-errors-health-care-settings-systematic-review
April 01, 2015 - systematic review estimates that nearly 1 in 5 medication doses is administered incorrectly in the inpatient … designed to improve medication safety for patients with monitored dosage systems following hospital discharge … Identifying systems failures in the pathway to a catastrophic event: an analysis of national incident report data … September 18, 2013
Drug administration errors in hospital inpatients: a systematic review
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psnet.ahrq.gov/issue/advanced-medication-reconciliation-systematic-review-impact-medication-errors-and-adverse
December 18, 2017 - Medication errors at hospital discharge are a common cause of medication errors and adverse drug events … This review compared three types of discharge medication reconciliation : paper-based, electronic, and … by face-to-face feedback to prescribers on adverse drug events recognition and prevention in older inpatients … August 10, 2022
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Related Resources
The secondary use of data
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psnet.ahrq.gov/issue/prevalence-underlying-causes-and-preventability-sepsis-associated-mortality-us-acute-care
August 20, 2018 - The degree to which sepsis contributes to inpatient mortality and the extent to which sepsis-associated … inpatient mortality is preventable remains unknown. … The authors conclude that it may be challenging to further reduce sepsis-associated inpatient mortality … Same Author(s)
Incidence and trends of sepsis in US hospitals using clinical vs claims data … impact of coronavirus disease 2019 (COVID-19) on healthcare-associated infections in 2020: a summary of data
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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,
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psnet.ahrq.gov/issue/enhancing-patient-safety-improving-patient-handoff-process-through-appreciative-inquiry
April 10, 2024 - March 11, 2020
Functional health literacy and understanding of medications at discharge … impact of evidence-based design strategies on patient safety, healing, and satisfaction in an adult inpatient … July 14, 2018
Diagnostic performance dashboards: tracking diagnostic errors using big data
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psnet.ahrq.gov/issue/implementing-warm-handoff-between-hospital-and-skilled-nursing-facility-clinicians
March 04, 2020 - Dropping the baton: a qualitative analysis of failures during the transition from emergency department to inpatient … November 13, 2024
Use of administrative data to find substandard care: validation of … 2019
A systematic literature review and narrative synthesis on the risks of medical discharge
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psnet.ahrq.gov/issue/world-health-organization-field-trial-assessing-proposed-icd-11-framework-classifying-patient
December 29, 2014 - ICD-10 codes for patient safety indicators for large-scale surveillance using administrative hospital data … February 28, 2024
A randomised controlled trial assessing the efficacy of an electronic discharge … December 6, 2017
Mitigating imperfect data validity in administrative data PSIs: a method … An analysis of the structure and content of dashboards used to monitor patient safety in the inpatient … contribution of staffing to medication administration errors: a text mining analysis of incident report data
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psnet.ahrq.gov/issue/artificial-intelligence-systems-complex-decision-making-acute-care-medicine-review
March 16, 2011 - Artificial intelligence (AI) technologies can improve the use of data in care delivery. … designed to improve medication safety for patients with monitored dosage systems following hospital discharge … June 28, 2017
A conceptual framework to reduce inpatient preventable deaths.
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psnet.ahrq.gov/issue/actions-needed-improve-newly-enrolled-veterans-access-primary-care
September 07, 2016 - The report outlines weaknesses in the data collected to measure and evaluate veterans' access to primary … October 12, 2022
Deficiencies in Inpatient Mental Health Care Coordination and Processes … August 15, 2012
Managing Patients' Medicines after Discharge from Hospital.
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psnet.ahrq.gov/node/60611/psn-pdf
June 24, 2020 - Pharmacokinetic
and pharmacodynamic data with single-dose and multiple-dose administration have been … Relevant variables, such as status of a patient’s renal function, can
be determined from data already … inpatient stay, new challenges arise as they resume responsibility for obtaining and managing their … 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
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psnet.ahrq.gov/issue/randomized-trial-electronic-clinical-reminders-improve-medication-laboratory-monitoring
June 11, 2014 - result was that clinicians were generally already monitoring patients as recommended—in contrast to data … A cross-sectional observational study of high override rates of drug allergy alerts in inpatient … July 16, 2019
Medication-related clinical decision support alert overrides in inpatients … a tool within the electronic medical record to facilitate medication reconciliation after hospital discharge
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psnet.ahrq.gov/node/49492/psn-pdf
November 01, 2005 - institutions,
most prominently Luther Midelfort Hospital, a Mayo affiliate.(1) Based on this work and the data … At the time of
discharge, his INR was noted to be 4. … To complete the process of medication reconciliation, at the time of discharge, the discharge prescriptions … must be reconciled with the most recent inpatient orders and the patient medication list prepared at … therapeutic duplication, possible drug interactions,
omissions, or medications not ordered during the inpatient
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psnet.ahrq.gov/issue/experiential-learning-through-local-implementation-national-chief-resident-quality-and
November 16, 2022 - Influence of organizational climate and clinician morale on seclusion and physical restraint use in inpatient … April 1, 2020
Impact of automated alerts on discharge opioid overprescribing after general … February 3, 2021
Comparison of traditional trigger tool to data warehouse based screening … Data consistency influences the relationship between diagnostic accuracy and certainty.
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psnet.ahrq.gov/issue/nurse-judgements-hospitalized-patients-safety-concerns-are-affected-patient-nurse-and-event
May 13, 2020 - mixed methods study examining teamwork shared mental models of interprofessional teams during hospital discharge … July 28, 2021
Integrating incident data from five reporting systems to assess patient … medical error in hospitals using incident-reporting systems, patient complaints and chart review of inpatient … April 14, 2011
Patient expectations of fair complaint handling in hospitals: empirical data