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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/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/periodic-issue/periodic-issue-470
December 31, 2024 - of recommendations met high methodological standards and identified a gap in pre-admission and post-discharge … of recommendations met high methodological standards and identified a gap in pre-admission and post-discharge … A novel finding was the potential "gaming" of technology wherein a patient enters falsified data to suggest … set of quality indicators supports the epidemiological or research program use of billing or claims data … The data can be applied to inform the development of population-level improvement strategies and track
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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/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/patient-safety-and-quality-improvement-medical-errors-and-adverse-events
October 18, 2006 - medical resident–pharmacist collaboration improves the rate of medication reconciliation verification at discharge … May 25, 2011
Inpatient safety outcomes following the 2011 residency work-hour reform. … Can routinely collected data be repurposed to predict avoidable patient harm? … July 23, 2008
Functional health literacy and understanding of medications at discharge … clinical handover between intensive care unit and general ward professionals at intensive care unit discharge
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psnet.ahrq.gov/node/33603/psn-pdf
September 15, 2024 - Background
According to data from AHRQ, more than 9 million inpatient stays involve surgical procedures … The most common types of inpatient surgical
procedures include obstetrical procedures (e.g., cesarean … common preventable complication after surgery, occurring in 2% to 4% of all patients
undergoing inpatient … Although SSIs are less common following ambulatory
surgery than after inpatient procedures, they are … interventions
to prevent SSIs (and HAIs in general) include improving safety culture, the use of robust data
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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/association-between-hospital-penalty-status-under-hospital-readmission-reduction-program-and
August 15, 2018 - This retrospective analysis of Medicare claims data found that the decrease in readmissions following … Association of changing hospital readmission rates with mortality rates after hospital discharge … February 15, 2011
Changes in outcomes for internal medicine inpatients after work-hour … hospital-acquired methicillin-resistant Staphylococcus aureus: hospital-level analysis of administrative data … The confused and bewildered hospital: adverse event discovery, pay-for-performance, and big data
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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/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/node/49776/psn-pdf
November 01, 2016 - educational value to trainees and created a system that facilitated poor clinical
performance.(6) Internal data … chance that their patients
received pap smears in the resident clinic approached zero (unpublished data … safety,
the learning environment, and resident–patient relationships, but no actual patient outcomes data … expanded on
Bodenheimer's previously described 10 aspects of high-performing care (engaged leadership, data-driven … Frequent measurement and sharing of data are first
steps to achieving a culture of shared responsibility
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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/node/33597/psn-pdf
April 10, 2024 - Long-term care settings include skilled nursing facilities (SNFs), inpatient rehabilitation facilities … Inpatient rehabilitation facilities (IRFs) care for patients recovering from surgery, trauma, or an … SOPS®) Nursing Home Survey is used to assess safety culture in
nursing home settings The most recent data … Long-term acute care
hospitals and inpatient rehabilitation facilities are accredited in the same fashion … nursing home patients and residents based
on the level and intensity of care needed, are still gathering data
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psnet.ahrq.gov/issue/implementation-patient-safety-program-tertiary-health-system-longitudinal-analysis
November 29, 2023 - March 14, 2018
The safety of inpatient health care. … Association of changing hospital readmission rates with mortality rates after hospital discharge … February 28, 2018
Medication errors resulting in harm: using chargemaster data to determine
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psnet.ahrq.gov/issue/drug-errors-qualitative-research-and-some-reflections-ethics
January 31, 2024 - An analysis of staff and patient survey data and routinely collected outcomes. … 2018
A qualitative study of patient involvement in medicines management after hospital discharge … March 17, 2011
Association between hospital-reported Leapfrog Safe Practices scores and inpatient
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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/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/issue/potentially-inappropriate-medications-defined-stopp-criteria-and-risk-adverse-drug-events
April 22, 2015 - August 18, 2021
Who makes prescribing decisions in hospital inpatients? … December 7, 2022
Perceived causes of prescribing errors by junior doctors in hospital inpatients … May 15, 2013
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/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 … an 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