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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/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/periodic-issue/periodic-issue-414
October 31, 2023 - designed to improve medication safety for patients with monitored dosage systems following hospital discharge … Miscommunication between hospitals and community pharmacists at patient discharge can result in incorrect … describes utilization and impact of the Transfers of Care Around Medicines (TCAM) service post-hospital discharge … identified – (1) information management such as incomplete medication lists or fragmentation of patient data … study was able to identify potential problems with both the old and new systems and provide performance 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
View More
Related Resources
Danger in discharge
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psnet.ahrq.gov/node/47267/psn-pdf
September 05, 2018 - Extrapolating medication order data
from a random sample of patients at a single academic medical center … over a 1-year period, researchers
estimate that in 2014 there were 29.7 million adult inpatient discharges
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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/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/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/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/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/issue/systematic-review-adult-admissions-icus-related-adverse-drug-events
March 16, 2016 - Assessing the use of Google Translate for Spanish and Chinese translations of emergency department discharge … April 8, 2019
Effect of alerts for drug dosage adjustment in inpatients with renal insufficiency … March 10, 2011
A clinical data warehouse-based process for refining medication orders … September 3, 2014
Drug administration errors in hospital inpatients: a systematic review
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psnet.ahrq.gov/periodic-issue/periodic-issue-329
February 23, 2022 - for Patient Safety (SEIPS) model, this study explored care transitions between operating rooms and inpatient … Study
Discrepancy between emergency department admission diagnosis and hospital discharge … of patients admitted from the ED to hospital explored the concordance of ED admission and hospital discharge … Commentary
Overstating inpatient deaths due to medical error erodes trust in healthcare … The psychiatry team recommended discharge with outpatient therapy; he was discharged with outpatient
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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/emedication-monitoring
April 25, 2018 - July 11, 2012
Inpatient Quality Indicators. … - Diagnostic Safety Version 1.0
June 29, 2022
Common formats for patient safety data … July 27, 2022
NPSD Data Spotlight, Patient Safety and COVID-19: A Qualitative Analysis … July 31, 2019
Medicines-related harm in the elderly post-hospital discharge. … November 21, 2018
Community-acquired and hospital-acquired medication harm among older inpatients
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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/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 … October 12, 2011
The efficacy of computer-enabled discharge communication interventions
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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/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/periodic-issue/periodic-issue-281
March 15, 2021 - Global Trigger tool in inpatient and geriatric settings). … Study
Mitigating imperfect data validity in administrative data PSIs: a method for estimating … In this retrospective study, researchers analyzed patient complaint and medical record data and found … Global Trigger tool in inpatient and geriatric settings). … as a skin breakdown on her “backside”; however, no rectal or genital exams were completed during her inpatient