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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.
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psnet.ahrq.gov/issue/ambulatory-care-adverse-events-and-preventable-adverse-events-leading-hospital-admission
April 11, 2011 - Analyzing data from the Utah and Colorado Medical Practice Study , investigators reviewed nearly 15,000 … hospital discharge records and discovered 587 adverse events, 31 of which were ambulatory care preventable … April 25, 2016
Paid malpractice claims for adverse events in inpatient and outpatient
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psnet.ahrq.gov/node/860049/psn-pdf
January 04, 2024 - a succinct narrative that
encapsulates the key points of the patient’s presentation and available data … of sentinel events, and up to half of communication failures occur during patient handoffs.7 In the
inpatient … providers rely on the discharge summary to learn the details of the hospital course. … Any loose ends left at the time of discharge,
therefore, must be clearly defined in the discharge summary … Medical errors in US pediatric inpatients with chronic conditions.
Pediatrics. 2012;130(4).
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psnet.ahrq.gov/issue/medication-reconciliation-reducing-drug-discrepancy-adverse-events
October 10, 2018 - Effect of health information exchange on recognition of medication discrepancies is interrupted when data … July 27, 2016
Acceptance of recommendations by inpatient pharmacy case managers: unintended … March 27, 2013
The effect of medication reconciliation in elderly patients at hospital discharge
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psnet.ahrq.gov/issue/limits-clinician-vigilance-ai-safety-bulwark
September 07, 2022 - September 7, 2022
Inpatient EHR user experience and hospital EHR safety performance. … Progress in interoperability: measuring US hospitals' engagement in sharing patient data … 31, 2014
Community pharmacy medication review, death and re-admission after hospital discharge
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psnet.ahrq.gov/issue/learning-without-borders-review-implementation-medical-error-reporting-medecins-sans
December 21, 2022 - 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/adoption-patient-centered-care-practices-physicians-results-national-survey
August 28, 2019 - View More
Related Resources
Primary care physician communication at hospital discharge … September 15, 2011
Multidisciplinary approach to inpatient medication reconciliation … health care quality and patient safety in the United States using readily available administrative data
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psnet.ahrq.gov/issue/how-much-diagnostic-safety-can-we-afford-and-how-should-we-decide-health-economics
March 24, 2021 - misdiagnosis in adult emergency department patients: a look-forward analysis with administrative claims data … 2021
Feasibility of patient-reported diagnostic errors following emergency department discharge … June 17, 2020
Patient safety in inpatient psychiatry: a remaining frontier for health
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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/patient-experience-must-move-beyond-bad-apples
September 02, 2009 - A pilot study examining undesirable events among emergency department–boarded patients awaiting inpatient … November 17, 2010
Emergency department discharge prescription interventions by emergency … , 2019
Missed diagnosis of cancer in primary care: insights from malpractice claims data
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psnet.ahrq.gov/issue/evaluation-symptom-checkers-self-diagnosis-and-triage-audit-study
December 08, 2021 - These data do not support the use of online symptom checkers for diagnosis or triage and argue for use … hospitalization among adult emergency department patients: a look-back analysis employing insurance claims data … December 8, 2021
Discrepancy between emergency department admission diagnosis and hospital discharge … July 31, 2019
Effect of patient- and medication-related factors on inpatient medication … March 14, 2018
Predicting the future—big data, machine learning, and clinical medicine
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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/stoppstart-criteria-potentially-inappropriate-prescribing-older-people-version-2
March 23, 2012 - August 18, 2021
Perceived causes of prescribing errors by junior doctors in hospital inpatients … Project (NAP5) on accidental awareness during general anaesthesia: protocol, methods, and analysis of data … October 9, 2013
Perceived causes of prescribing errors by junior doctors in hospital inpatients … June 22, 2009
Risk of medication errors at hospital discharge and barriers to problem
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psnet.ahrq.gov/issue/do-clinicians-know-which-their-patients-have-central-venous-catheters-multicenter
June 08, 2016 - This study sought to determine whether inpatient physicians know which of their patients have CVCs in … December 21, 2017
Electronic health records, communication, and data sharing: challenges … WebM&M Cases
Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge
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psnet.ahrq.gov/issue/how-do-hospital-inpatients-conceptualise-patient-safety-qualitative-interview-study-using
July 08, 2020 - Study
How do hospital inpatients conceptualise patient safety? … How do hospital inpatients conceptualise patient safety? … How do hospital inpatients conceptualise patient safety? … respond to errors in their personal health records: mixed methods analysis of cross-sectional survey data
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psnet.ahrq.gov/web-mm/finding-fault-default-alert
August 28, 2024 - However, the discharge prescription was erroneously written as phenytoin 500 mg "three times daily" ( … In review of the resident's discharge note, the discharge plan for the phenytoin was clearly stated, … three clinical decision support systems: prospective screening for medication errors in 100 medical inpatients … Author(s)
Developing a process to measure actual harm from medication errors in paediatric inpatients … December 23, 2020
The tradeoffs between safety and alert fatigue: data from a national
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psnet.ahrq.gov/node/857059/psn-pdf
November 29, 2023 - Another recognized vulnerability is through transitions in environments of care, such as from inpatient … to
subacute rehabilitation care, where interfacility data transmission remains highly susceptible to … 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/issue/national-cross-sectional-cohort-study-relationship-between-quality-mental-healthcare-and
May 04, 2022 - Previous research has emphasized suicide prevention in inpatient mental health settings , but less is … Using longitudinal data from 2013 to 2017, this study found no relationship between overall quality of … From the Same Author(s)
Is it time for the mental health field to consider unplanned discharge
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psnet.ahrq.gov/issue/electronic-prescribing-subcutaneous-infusions-and-after-study-assessing-impact-upon-patient
July 06, 2022 - After implementation, rates of prescription errors , time to process discharge orders, and time between … of a computer-assisted tool with automated electronic integration of population-based community drug data … 2022
The frequency of inappropriate nonformulary medication alert overrides in the inpatient
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psnet.ahrq.gov/issue/whole-patient-measure-safety-using-administrative-data-assess-probability-highly-undesirable
March 19, 2014 - Study
Whole-patient measure of safety: using administrative data to assess the probability … Whole-patient measure of safety: using administrative data to assess the probability of highly undesirable … This study used screening of administrative data to determine the overall probability of an individual … Association of hospital participation in a surgical outcomes monitoring program with inpatient … August 2, 2015
Data as a catalyst for change: stories from the frontlines.