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psnet.ahrq.gov/issue/clinical-decision-support-early-recognition-sepsis
July 29, 2020 - Related Resources From the Same Author(s)
The tradeoffs between safety and alert fatigue: data … Renal medication-related clinical decision support (CDS) alerts and overrides in the inpatient … May 26, 2011
Impact of clinical decision support therapeutic interchanges on hospital discharge
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psnet.ahrq.gov/issue/use-patient-pictures-and-verification-screens-reduce-computerized-provider-order-entry-errors
November 16, 2022 - 2022
Feasibility of patient-reported diagnostic errors following emergency department discharge … February 18, 2011
A trigger tool to detect harm in pediatric inpatient settings. … View More
Related Resources
Assessment of the use of patient vital sign data
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psnet.ahrq.gov/issue/delivering-high-quality-cancer-care-charting-new-course-system-crisis
August 15, 2012 - Cancer patients are particularly vulnerable to preventable errors in both inpatient and outpatient … leveraging information technology to augment care coordination and real-time analysis of treatment data … October 8, 2014
Facilitating Patient Understanding of Discharge Instructions: Workshop
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psnet.ahrq.gov/issue/survey-hospital-quality-improvement-activities
January 27, 2019 - United States and provided an important stimulus for ongoing quality improvement (QI) efforts in the inpatient … Resources From the Same Author(s)
Evaluating the implementation of Project Re-Engineered Discharge … 16, 2022
Partnering with VA stakeholders to develop a comprehensive patient safety data
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psnet.ahrq.gov/issue/variation-printed-handoff-documents-results-and-recommendations-multicenter-needs-assessment
June 25, 2014 - Based on these findings, the authors make recommendations for the core data elements for written signouts … July 18, 2016
Inpatient housestaff discontinuity of care and patient adverse events. … reliability of verbal communication between primary care physicians and pediatric hospitalists at hospital discharge
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psnet.ahrq.gov/issue/cross-sectional-study-relationship-between-utilization-root-cause-analysis-and-patient-safety
January 11, 2017 - However, there is little objective data supporting its effectiveness. … September 19, 2016
A checklist to identify inpatient suicide hazards in Veterans Affairs … October 11, 2023
Is it time for the mental health field to consider unplanned discharge
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psnet.ahrq.gov/issue/patient-safety-plastic-surgery-identifying-areas-quality-improvement-efforts
November 01, 2017 - Related Resources From the Same Author(s)
Opioid abuse and poisoning: trends in inpatient … The TRANSFORM patient safety project: a microsystem approach to improving outcomes on inpatient … and 6 years of Alabama data reveal. … February 10, 2012
Office surgery incidents: what seven years of Florida data show us. … July 10, 2008
Promoting a culture of patient safety: a review of the Florida moratoria data
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psnet.ahrq.gov/perspective/beyond-hospital-new-frontier-patient-safety
August 01, 2014 - 400 patients discharged from a tertiary academic hospital, 19% had an adverse event within 3 weeks of discharge … , and 30% of these resulted in a nonpermanent disability or worse.( 5 ) A review of 14,700 discharge … Is ambulatory patient safety just like inpatient patient safety? … The incidence and severity of adverse events affecting patients after discharge from the hospital. … Much of your data is now publicly reported. There's value-based purchasing.
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psnet.ahrq.gov/perspective/conversation-urmimala-sarkar-md-mph
August 22, 2014 - Much of your data is now publicly reported. There's value-based purchasing. … 400 patients discharged from a tertiary academic hospital, 19% had an adverse event within 3 weeks of discharge … , and 30% of these resulted in a nonpermanent disability or worse.( 5 ) A review of 14,700 discharge … Is ambulatory patient safety just like inpatient patient safety? … The incidence and severity of adverse events affecting patients after discharge from the hospital.
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psnet.ahrq.gov/node/49614/psn-pdf
November 01, 2010 - At another local teaching hospital, a family had given incorrect data to the ED staff (including listing … Features specific to electronic data such as auto-completion during data entry (
4), copying and pasting … Defense 1: EHR Interoperability
In both cases, had the inpatient and outpatient EHRs been able to "talk … were using any medication reconciliation procedures, which might
have prevented errors by the ED and discharge … team in Case 1 and the inpatient team in Case 2.
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psnet.ahrq.gov/issue/monitoring-patient-safety-primary-care-exploratory-study-using-depth-semistructured
December 14, 2016 - barriers to patient safety in primary care and offered specific recommendations for improving the use of data … December 14, 2016
Investigating adverse event free admissions in Medicare inpatients … January 7, 2015
A review of patient safety measures based on routinely collected hospital data … March 12, 2014
Managing Patients' Medicines after Discharge from Hospital.
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psnet.ahrq.gov/issue/racial-disparities-preventable-adverse-events-attributed-poor-care-coordination-reported
January 18, 2023 - study evaluated racial disparities in self-reported adverse events based on cross-sectional survey data … impact of coronavirus disease 2019 (COVID-19) on healthcare-associated infections in 2020: a summary of data … by face-to-face feedback to prescribers on adverse drug events recognition and prevention in older inpatients … August 10, 2022
Implementation of a discharge education program to improve transitions
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psnet.ahrq.gov/issue/report-information-technology-and-health-deficiencies-us-nursing-homes
October 28, 2020 - This study used publicly available nursing home data and a survey on IT sophistication to identify … of a computer-assisted tool with automated electronic integration of population-based community drug data … April 29, 2018
A randomised controlled trial assessing the efficacy of an electronic discharge … December 6, 2017
Efficiency and interpretability of text paging communication for medical inpatients
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psnet.ahrq.gov/issue/patient-reported-service-quality-medicine-unit
February 24, 2011 - The investigators interviewed patients during hospitalization and after discharge to identify service … February 24, 2011
Do medical inpatients who report poor service quality experience more … September 23, 2020
Use of administrative data to find substandard care: validation of
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psnet.ahrq.gov/issue/competition-and-health-plan-performance-evidence-health-maintenance-organization-insurance
July 14, 2009 - Evaluating the Patient Safety Indicators: how well do they perform on Veterans Health Administration data … January 4, 2012
Association between unmet nonmedication needs after hospital discharge … May 24, 2015
Paid malpractice claims for adverse events in inpatient and outpatient settings
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psnet.ahrq.gov/web-mm/myasthenia-crisis-after-delayed-diagnosis-medically-complex-patient
February 21, 2020 - a succinct narrative that encapsulates the key points of the patient’s presentation and available data … 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.
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psnet.ahrq.gov/issue/association-between-hospital-performance-patient-safety-and-30-day-mortality-and-unplanned
June 22, 2022 - Utilizing data from the AHRQ Medicare Patient Safety Monitoring System and the Centers for Medicare and … Association of changing hospital readmission rates with mortality rates after hospital discharge … September 1, 2018
Impact of inpatient harms on hospital finances and patient clinical
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psnet.ahrq.gov/issue/rates-and-types-events-reported-established-incident-reporting-systems-two-us-hospitals
January 02, 2017 - for US hospitals to maintain incident reporting systems, little is known about the utility of the data … This study linked incident report and discharge databases at two hospitals to examine how frequently … A prior commentary proposed a theoretical framework for using incident reporting data to improve safety … April 22, 2012
Evaluation of an anonymous system to report medical errors in pediatric inpatients
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psnet.ahrq.gov/issue/agency-healthcare-research-and-quality-pediatric-indicators-quality-metric-surgery-children
May 01, 2015 - Research and Quality's Patient Safety Indicators (PSIs) are widely used to screen administrative data … for evidence of adverse events in adult inpatients. … January 29, 2020
Safety of overlapping inpatient orthopaedic surgery: a multicenter study … August 8, 2013
Medical large language models are vulnerable to data-poisoning attacks
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psnet.ahrq.gov/issue/childrens-hospitals-solutions-patient-safety-collaborative-impact-hospital-acquired-harm
August 10, 2022 - All but one submitted their safety data for inclusion in the study. … July 19, 2018
A trigger tool to detect harm in pediatric inpatient settings. … , 2017
Improving communication with primary care physicians at the time of hospital discharge