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psnet.ahrq.gov/issue/risk-factors-associated-medication-ordering-errors
December 02, 2020 - electronic medication systems in reducing medication error rates and associated harm among hospital inpatients … of a computer-assisted tool with automated electronic integration of population-based community drug data … Analysis of the nature and contributory factors of medication safety incidents following hospital discharge … using National Reporting and Learning System (NRLS) data from England and Wales: a multi-method study … August 24, 2022
The tradeoffs between safety and alert fatigue: data from a national
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psnet.ahrq.gov/issue/association-label-drug-use-and-adverse-drug-events-adult-population
February 03, 2011 - of a computer-assisted tool with automated electronic integration of population-based community drug data … December 3, 2018
Failure to follow medication changes made at hospital discharge is associated … June 17, 2020
Usage and accuracy of medication data from nationwide health information … A cross-sectional observational study of high override rates of drug allergy alerts in inpatient
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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/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/issue/importance-prevention-and-early-intervention-adverse-events-pediatric-cardiac-catheterization
March 24, 2019 - December 4, 2024
Clinical data sharing improves quality measurement and patient safety … 25, 2022
Community pharmacy medication review, death and re-admission after hospital discharge … October 31, 2011
An inpatient fall prevention initiative in a tertiary care hospital.
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psnet.ahrq.gov/issue/dying-weekend-retrospective-cohort-study-association-between-day-hospital-presentation-and
April 18, 2012 - Same Author(s)
A review of patient safety measures based on routinely collected hospital data … December 9, 2015
Investigating adverse event free admissions in Medicare inpatients as … January 19, 2014
Validity of AHRQ patient safety indicators derived from ICD-10 hospital discharge … abstract data (chart review study). … : case-control analysis and comparison with US data.
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psnet.ahrq.gov/issue/determinants-adverse-events-vascular-surgery
March 21, 2012 - The PSIs are best used to screen administrative data for potential adverse events, as in this study. … February 10, 2012
Opioid abuse and poisoning: trends in inpatient and emergency department … The TRANSFORM patient safety project: a microsystem approach to improving outcomes on inpatient … of selected AHRQ Patient Safety Indicators based on VA National Surgical Quality Improvement program data
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psnet.ahrq.gov/issue/missed-and-delayed-diagnoses-ambulatory-setting-study-closed-malpractice-claims
October 26, 2010 - This study analyzed data from malpractice claims at four liability insurers, similar to companion studies … below, considers the differences in the nature of errors and approaches to solving them between the inpatient … 2011
Impact of an automated email notification system for results of tests pending at discharge
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psnet.ahrq.gov/issue/physician-scores-national-clinical-skills-examination-predictors-complaints-medical
October 16, 2019 - February 14, 2017
Failure to follow medication changes made at hospital discharge is … of a computer-assisted tool with automated electronic integration of population-based community drug data … June 2, 2021
Usage and accuracy of medication data from nationwide health information … January 31, 2013
Do medical inpatients who report poor service quality experience more
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psnet.ahrq.gov/issue/responding-safe-care-healthcare-staff-experiences-caring-child-intellectual-disability
June 15, 2022 - March 17, 2021
Inpatient telemedicine and new models of care during COVID-19: hospital … respond to errors in their personal health records: mixed methods analysis of cross-sectional survey data … September 26, 2018
Facilitating Patient Understanding of Discharge Instructions: Workshop
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psnet.ahrq.gov/issue/identifying-potential-prescribing-safety-indicators-related-mental-health-disorders-and
July 22, 2020 - Author(s)
Prevalence and nature of medication errors and medication-related harm following discharge … September 15, 2021
The psychological experiences of nurses after inpatient suicide: a … October 8, 2013
A review of patient safety measures based on routinely collected hospital data
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psnet.ahrq.gov/issue/influencing-culture-quality-and-safety-through-huddles
April 05, 2023 - of a computer-assisted tool with automated electronic integration of population-based community drug data … October 5, 2022
Developing and aligning a safety event taxonomy for inpatient psychiatry … July 13, 2022
Is it time for the mental health field to consider unplanned discharge
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psnet.ahrq.gov/issue/improving-specificity-drug-drug-interaction-alerts-can-it-be-done
September 07, 2022 - of a computer-assisted tool with automated electronic integration of population-based community drug data … April 13, 2022
Impact of clinical decision support therapeutic interchanges on hospital discharge … events by application of a probabilistic, machine-learning based clinical decision support system in an inpatient
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psnet.ahrq.gov/issue/clinical-supervision-general-practice-training-interweaving-supervisor-trainee-and-patient
October 13, 2021 - of a computer-assisted tool with automated electronic integration of population-based community drug data … An analysis of the structure and content of dashboards used to monitor patient safety in the inpatient … December 8, 2021
View More
Related Resources
Danger in discharge
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psnet.ahrq.gov/issue/understanding-communication-during-hospitalist-service-changes-mixed-methods-study
December 14, 2022 - Evaluating the Patient Safety Indicators: how well do they perform on Veterans Health Administration data … August 12, 2020
Do medical inpatients who report poor service quality experience more … November 23, 2016
Promoting effective transitions of care at hospital discharge: a review
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psnet.ahrq.gov/issue/performance-measures-neurosurgical-patient-care-differing-applications-patient-safety
June 03, 2020 - The AHRQ Patient Safety Indicators (PSIs) can identify adverse events in hospital data. … May 4, 2012
Opioid abuse and poisoning: trends in inpatient and emergency department … The TRANSFORM patient safety project: a microsystem approach to improving outcomes on inpatient
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psnet.ahrq.gov/web-mm/reconciling-records
September 01, 2017 - 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 " … 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/reducing-failures-daily-medical-practice-healthcare-failure-mode-and-effect-analysis-combined
August 10, 2022 - Use of HFMEA-CS to analyze medication processes during admission and discharge for patients with a rare … by face-to-face feedback to prescribers on adverse drug events recognition and prevention in older inpatients … 2021
Performance variability in perioperative sentinel events: report on a nationwide data
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psnet.ahrq.gov/issue/reducing-error-anticoagulant-dosing-multidisciplinary-team-rounding-point-care
November 16, 2016 - This study suggests that integration of a clinical pharmacist into the inpatient team may help prevent … The alarming reality of medication error: a patient case and review of Pennsylvania and national data … April 24, 2018
Clinical impact of medication review and deprescribing in older inpatients
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psnet.ahrq.gov/node/49518/psn-pdf
August 01, 2006 - Consider first the medication use process in the inpatient setting. … of treatment-related hypoglycemia is particularly high
among frail elderly patients after hospital discharge … Advance
Data from Vital and Health Statistics, No. 374. … Available at: http://www.cdc.gov/nchs/data/ad/ad374.pdf. Accessed July 5, 2006.
2. Table 2. … Available at:
http://www.cdc.gov/nchs/data/ad/ad374.pdf
http://www.census.gov/prod/2005pubs/06statab