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psnet.ahrq.gov/issue/reduction-warfarin-adverse-events-requiring-patient-hospitalization-after-implementation
October 23, 2024 - Resources 
 
 
 
 
 
 
 Prevented harm and cost avoidance with pharmacist intervention while utilizing a discharge … associated direct acting oral anticoagulants (DOACs) medication incidents: evaluation of real world data … December 23, 2016 
 
 
 
 
 
 
 
 Clinical and safety impact of an inpatient pharmacist-directed anticoagulation
                                     
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.107_slideshow.ppt
November 01, 2005 - history possible, verifying that list, and comparing it with orders written at admission, transfer, and discharge … to communicate when an intentional medication change is made
Medication Reconciliation: The Data … Case (cont.): Reconciling Doses
	At the time of discharge, the patient’s INR was noted to be 4. … measurement strategy to determine program’s effectiveness
	Assessment form available here
	Collecting data … , reconcile prescriptions with most recent inpatient orders and patient medication list prepared at admission
                                     
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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/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/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/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/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/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/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/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.
                                     
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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/implementing-safety-thermometer-tool-one-nhs-trust
March 19, 2019 - April 13, 2022 
 
 
 
 
 
 
 
 Improving discharge safety in a pediatric emergency department. … April 24, 2018 
 
 
 
 
 
 
 
 Using medicolegal data to support safe medical care: a contributing factor … May 13, 2020 
 
 
 
 
 
 
 
 An organization-specific and modifiable inpatient safety composite measure
                                     
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psnet.ahrq.gov/issue/antidepressant-and-antipsychotic-medication-errors-reported-united-states-poison-control
March 24, 2021 - Using data from the National Poison Data System from 2000 to 2012, researchers found that  medication … 2020 
 
 
 
 
 
 
 
 Prevalence and nature of medication errors and medication-related harm following discharge … 2017 
 
 
 
 
 
 
 
 An observational study of medication administration errors in old-age psychiatric inpatients
                                     
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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/web-mm/when-taking-sglt2-inhibitor-remember-sstop-stop-sglt2-inhibitor-three-days-bef-o-re
February 01, 2023 - Lab Value (normal range) Pre-Procedure Day of Procedure Day After Procedure Readmission (day after discharge … He was told only to hold it on the day of the procedure, and to resume all medications after discharge … Tan, MSN, ACNP-BC, CDCES, BC-ADM Inpatient Glycemic Team Nurse Practitioner Patient Care Services UC … Ketoacidosis associated with SGLT2 inhibitor treatment: Analysis of FAERS data. … February 1, 2023 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 WebM&M Cases 
 
 
 
 
 
 
 
 
 
 Inpatient Stroke
                                     
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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/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