- 
                                        
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/issue/suicide-attempts-after-emergency-room-visits-effect-patient-safety-goals
August 04, 2021 - These observational data suggest that implementing the goal may have increased identification of suicidal … A previous  WebM&M commentary  discussed suicide after discharge. … Surgeon information transfer and communication: factors affecting quality and efficiency of inpatient
                                     
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psnet.ahrq.gov/issue/perspectives-emergency-clinicians-about-medical-errors-resulting-patient-harm-or-malpractice
October 13, 2021 - October 13, 2021 
 
 
 
 
 
 
 
 Inpatient patient safety events in vulnerable populations: a retrospective … in the US Veterans Affairs health care system: a qualitative study of aggregated root cause analysis data … 27, 2022 
 
 
 
 
 
 
 
 Discrepancy between emergency department admission diagnosis and hospital discharge … hospitalization among adult emergency department patients: a look-back analysis employing insurance claims data … misdiagnosis in adult emergency department patients: a look-forward analysis with administrative claims data
                                     
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psnet.ahrq.gov/web-mm/correct-treatment-plan-incorrect-diagnosis-pharmacist-intervention
May 01, 2011 - Following her discharge, the results of a full infectious disease panel returned showing a nonreactive … majority of medication-related problems also occur during these transitions, especially at admission and discharge … time includes reading notes (e.g., admission notes and progress notes), followed by medication lists (inpatient … using the EHR and integration with clinical teams in the inpatient setting has markedly improved patient … Take-Home Points     Medication errors during transitions of care, particularly at admission and discharge
                                     
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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/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/hospital-board-and-management-practices-are-strongly-related-hospital-performance-clinical
October 27, 2021 - This study, which used survey data from a large sample of hospitals in the United States and England, … 2021 
 
 
 
 
 
 
 
 Prevalence and nature of medication errors and medication-related harm following discharge … 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/sites/default/files/2023-11/spotlight_case_the_risk_of_malpositioned.pdf
January 01, 2023 - – With transitions in environments of care, such as from inpatient to subacute rehabilitation care, … interfacility 
data transmission remains highly susceptible to loss or degradation.40-44
• With the … courses and complex post-discharge planning 
needs. … This information can be propagated through progress notes and included on discharge 
summaries, discharge … Creating a better discharge summary: improvement in quality and timeliness using an electronic discharge
                                     
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psnet.ahrq.gov/node/73899/psn-pdf
September 29, 2021 - However,
her actual discharge prescription, which was not mentioned on the discharge summary, was … readmitted to the hospital several weeks later for increasing pain and was restarted on her
previous inpatient … Clear Communication
In this case, lack of communication in transitions of care from inpatient to outpatient … Florence Tan, PharmD, BCPS, BCGP
Department of Inpatient Pharmacy, General Medicine
UC Davis Health … Medicine, Hospital Medicine
UC Davis Health
kkjohl@ucdavis.edu
Mariya Kotova, PharmD
Department of Inpatient
                                     
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psnet.ahrq.gov/issue/reduce-readmissions-pharmacy-programs-focus-transitions-hospital-community
September 26, 2016 - Mismatched prescribing and pharmacy templates for parenteral nutrition (PN) lead to data … Economic value of pharmacist-led medication reconciliation for reducing medication errors after hospital discharge … January 22, 2014 
 
 
 
 
 
 
 
 Acceptance of recommendations by inpatient pharmacy case managers: unintended
                                     
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psnet.ahrq.gov/issue/reducing-prognostic-errors-new-imperative-quality-healthcare
June 21, 2016 - 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/issue/designing-safer-radiology-department
March 04, 2015 - April 21, 2011 
 
 
 
 
 
 
 
 Medical large language models are vulnerable to data-poisoning attacks … October 19, 2022 
 
 
 
 
 
 
 
 Effect of patient- and medication-related factors on inpatient medication … September 23, 2020 
 
 
 
 
 
 
 
 Medication safety at the interface: evaluating risks associated with discharge
                                     
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psnet.ahrq.gov/issue/minnesota-hospital-association-statewide-project-safe-falls
May 05, 2014 - A cross-sectional observational study of high override rates of drug allergy alerts in inpatient … September 24, 2017 
 
 
 
 
 
 
 
 Engaging patients in the use of real-time electronic clinical data … May 4, 2022 
 
 
 
 
 
 
 
 SAFER Care: improving caregiver comprehension of discharge instructions.
                                     
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psnet.ahrq.gov/node/49762/psn-pdf
June 01, 2016 - The ED providers contacted the
inpatient internal medicine team for admission. … https://psnet.ahrq.gov/web-mm/case-mistaken-intubation
The inpatient team happened to be the same team … Physician Orders for Life-Sustaining Therapy), and the
team had clearly documented his wishes in the discharge … There is little data regarding how often such unwanted resuscitations occur. … upload his POLST, and this would have been stored in the system's EHR at the time of the
original discharge
                                     
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psnet.ahrq.gov/issue/development-trigger-tool-identify-adverse-drug-events-elderly-patients-multimorbidity
December 02, 2020 - by face-to-face feedback to prescribers on adverse drug events recognition and prevention in older inpatients … August 10, 2022 
 
 
 
 
 
 
 
 Drug-drug interactions and prescription appropriateness at hospital discharge … August 7, 2019 
 
 
 
 
 
 
 
 The effect of medication reconciliation in elderly patients at hospital discharge … September 9, 2010 
 
 
 
 
 
 
 
 Consistency between coded poison center data and fatality abstract
                                     
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psnet.ahrq.gov/issue/patient-safety-indicators-academic-veterans-affairs-hospital-addressing-dual-goals-clinical
August 09, 2023 - In this study, one Veterans Affairs (VA) hospital implemented three clinical care and two accurate data … "Sign right here and you're good to go": a content analysis of audiotaped emergency department discharge … January 10, 2024 
 
 
 
 
 
 
 
 Sources of nurse-sensitive inpatient safety improvement.
                                     
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psnet.ahrq.gov/issue/effect-clinical-experience-error-rate-emergency-physicians
November 16, 2022 - This study analyzed case review data from a single emergency department over a 7-year period. … 2018 
 
 
 
 
 
 
 
 Adverse events in patients transitioning from the emergency department to the inpatient … September 27, 2016 
 
 
 
 
 
 
 
 Pediatric emergency department discharge prescriptions requiring pharmacy
                                     
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psnet.ahrq.gov/issue/changes-hospital-adverse-events-and-patient-outcomes-associated-private-equity-acquisition
July 12, 2023 - There was no change in 30-day mortality after hospital discharge, but in-hospital mortality decreased … September 13, 2023 
 
 
 
 
 
 
 
 A multi-site assessment of inpatient safety event rates during the … More 
 
 
 
 
 
 Related Resources 
 
 
 
 
 
 
 Leapfrog safety grades in California hospitals: a data
                                     
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psnet.ahrq.gov/issue/future-artificial-intelligence-applications-cancer-care-global-cross-sectional-survey
April 27, 2022 - Lack of standardization in health data was rated as the most likely barrier to use of AI. … August 5, 2020 
 
 
 
 
 
 
 
 A toolkit to disseminate best practices in inpatient medication reconciliation … September 9, 2013 
 
 
 
 
 
 
 
 Medication reconciliation at hospital discharge: evaluating discrepancies
                                     
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psnet.ahrq.gov/perspective/conversation-withvineet-arora-md-ma
March 01, 2011 - this risk stratification there's different expectations of the time it will take and the amount of data … For some, like readmission or discharge, that makes intuitive sense, but for a specific inpatient handoff … Our data does show that some people do recognize the tradeoff. … What Have We Learned About Safe Inpatient Handovers? … Recommendations for Inpatient Handovers.* 
 (Go to table citation in the text) 
 
 
 
 
 1.