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psnet.ahrq.gov/web-mm/admission-drug-dose-too-low
September 01, 2011 - A study of adult inpatients found 5.3 errors per 100 orders, with 6.6% being near misses and 0.9% resulting … Classifying and predicting errors of inpatient medication reconciliation. … User experiences with pharmacy benefit manager data at point of care. … Unit-based clinical pharmacists' prevention of serious medication errors in pediatric inpatients … December 30, 2014
WebM&M Cases
Treatment Challenges After Discharge
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psnet.ahrq.gov/issue/factor-structure-and-construct-validity-hospital-survey-patient-safety-culture-using
June 29, 2022 - Exploratory factor analysis was conducted with SOPS data to compare with the six components of Patient … Effect of pharmacist counseling intervention on health care utilization following hospital discharge … by face-to-face feedback to prescribers on adverse drug events recognition and prevention in older inpatients
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psnet.ahrq.gov/node/41100/psn-pdf
February 01, 2012 - Healthcare Research and Quality's Patient Safety Indicators (PSIs) are widely used to
screen administrative data … for evidence of adverse events in adult inpatients.
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psnet.ahrq.gov/issue/electronic-approaches-making-sense-text-adverse-event-reporting-system
August 03, 2022 - September 28, 2022
Harnessing the power of medical malpractice data to improve patient … July 7, 2021
Engaging patients in the use of real-time electronic clinical data to improve … February 10, 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/adding-automation-and-independent-dual-verification-reduce-wrong-blood-tube-wbit-events
October 21, 2020 - 22, 2011
Discrepancy between emergency department admission diagnosis and hospital discharge … hospitalization among adult emergency department patients: a look-back analysis employing insurance claims data … reduce duration and variability in delays to identification of serious injury after falls in hospital inpatients … 2022
Descriptive analysis of patient misidentification from incident report system data
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psnet.ahrq.gov/issue/medication-prescribing-errors-teaching-hospital-9-year-experience
February 10, 2011 - July 23, 2018
Impact of an inpatient electronic prescribing system on prescribing error … July 11, 2018
Errors in electronic health record–based data query of statin prescriptions … May 2, 2018
Assessment of emergency department antibiotic discharge prescription dosing
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psnet.ahrq.gov/issue/prevalence-copied-information-attendings-and-residents-critical-care-progress-notes
September 28, 2017 - Exploring the association between organizational safety climate, failure to rescue, and mortality in inpatient … May 31, 2023
Patient harm and institutional avoidability of out-of-hours discharge from … July 24, 2019
Data omission by physician trainees on ICU rounds.
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psnet.ahrq.gov/issue/framework-evaluating-appropriateness-clinical-decision-support-alerts-and-responses
March 21, 2017 - August 4, 2021
Clinical data sharing improves quality measurement and patient safety. … February 14, 2017
The incidence and severity of adverse events affecting patients after discharge … Renal medication-related clinical decision support (CDS) alerts and overrides in the inpatient
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psnet.ahrq.gov/issue/quality-pharmacologic-care-vulnerable-older-patients
August 27, 2012 - Design and implementation of an automated email notification system for results of tests pending at discharge … July 29, 2020
Medical large language models are vulnerable to data-poisoning attacks. … March 11, 2011
Appropriateness of use of medicines in elderly inpatients: qualitative
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psnet.ahrq.gov/issue/patient-outcomes-after-introduction-statewide-icu-nurse-staffing-regulations
June 19, 2019 - Association of hospital participation in a surgical outcomes monitoring program with inpatient … April 15, 2016
Whole-patient measure of safety: using administrative data to assess the … Policy, Research, and Patient Care
August 1, 2009
The relationship between inpatient … cardiac surgery mortality and nurse numbers and educational level: analysis of administrative data.
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psnet.ahrq.gov/issue/declaring-uncertainty-using-quality-improvement-methods-change-conversation-diagnosis
April 01, 2020 - This article outlines a process for identifying pediatric inpatients with uncertain diagnoses and improving … April 24, 2018
SAFER Care: improving caregiver comprehension of discharge instructions … impact of coronavirus disease 2019 (COVID-19) on healthcare-associated infections in 2020: a summary of data
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psnet.ahrq.gov/web-mm/double-trouble
August 01, 2012 - the Table .( 3 )
Although research data are limited, a number of recommendations for preventing medication … Adverse events among medical patients after discharge from hospital. … The patient’s condition was inadequately monitored after discharge. … The electrolyte levels were not monitored after discharge. … Hydrogen Ions
April 28, 2021
WebM&M Cases
Inpatient
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psnet.ahrq.gov/node/49550/psn-pdf
December 01, 2007 - death in low-risk DRGs as a patient safety indicator is that it can be measured
using administrative data … Measures of Patient Safety Based on Hospital
Administrative Data—The Patient Safety Indicators. … 100 patients with
discharges in DRGs associated with mortality rate less than
0.5%, based on 1997 data … from the National Inpatient
Sample Excludes patients with any code for cancer, trauma,
or an immunocompromised … complications while in
hospital
All discharges with disposition of "deceased" per 100
patients with discharge
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psnet.ahrq.gov/web-mm/delayed-recognition-positive-blood-culture
January 29, 2020 - On the day of discharge, the blood culture that was positive for gram-positive rods had now speciated … However, this result was not communicated to the primary medical team prior to the patient's discharge … An estimated 11% of inpatient microbiology tests result after discharge and approximately 2% of those … The hazard of using additional data. JAMA. 1976;236:1259-1263. [go to PubMed] 3. … Patient safety concerns arising from test results that return after hospital discharge.
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psnet.ahrq.gov/web-mm/language-barrier
February 28, 2024 - At the time of discharge from the hospital, the nurse counseled the parents on proper dosing through … of medical errors, so we do not know how common such errors are, nor what kinds of errors occur in inpatient … A recent study revealed that Spanish-speaking pediatric inpatients requesting an interpreter had more … ; however, none of the regulations require or even mention collecting such data, either.( 13 ) … Racial, Ethnic and Primary Language Data Collection: An Assessment of Federal Policies, Practices
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psnet.ahrq.gov/issue/if-no-one-stops-me-ill-make-mistake-again-changing-prescribing-behaviours-through-feedback
July 01, 2017 - These data should inform future efforts to provide prescribing feedback . … 2014
Prevalence, nature, severity and risk factors for prescribing errors in hospital inpatients … June 30, 2011
Pharmacists' interventions in prescribing errors at hospital discharge:
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psnet.ahrq.gov/issue/there-link-between-nursing-home-reported-quality-and-covid-19-cases-evidence-california
June 30, 2021 - This study combined quality ratings from Nursing Home Compare with state-level data to examine the … Download Citation
Related Resources From the Same Author(s)
Community discharge … between double-checking and medication administration errors: a direct observational study of paediatric inpatients
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psnet.ahrq.gov/issue/prevalence-and-characterisation-diagnostic-error-among-7-day-all-cause-hospital-medicine
April 12, 2023 - characterized diagnostic errors among adult patients readmitted to the hospital within 7 days of hospital discharge … between double-checking and medication administration errors: a direct observational study of paediatric inpatients … elderly fallers: identifying associated risk factors for 30-day unplanned readmissions using a clinical data
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psnet.ahrq.gov/web-mm/dropping-new-lows
December 18, 2024 - The sole use of sliding scale insulin in the inpatient setting is strongly discouraged . … Because of this, the providers were often reacting to old or incomplete data. … The inpatient diabetes team can act as consultants, change agents, and educators. … Having easily accessible and timely glucose and insulin data is the only way providers can make appropriate … Afterwards
September 1, 2006
WebM&M Cases
Discharge
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.293_slideshow.ppt
March 01, 2013 - Mistake (2)
The following evening, the patient's mother called the ED to report that the patient's discharge … Medication errors and adverse drug events in pediatric inpatients. … user
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Recommendation #4
Biomedical device integration (the ability to integrate data from … integrated EMRs, where automated calculations and CDS algorithms drive patient care, bad foundational data … *
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Take-Home Points (2)
To prevent data entry error of important values such as patient weight