- 
                                        
psnet.ahrq.gov/web-mm/critical-echocardiogram-result-lost-follow
July 31, 2023 - The results of the echocardiogram were pending on discharge, with anticipation that the patient’s primary … unexpected findings, of which potential neoplasms were discovered in 11%. 22  Although no baseline data … extra layer of reinforcement to ensure that primary care providers close the loop regarding pending inpatient … The safety of inpatient health care. … Patient safety concerns arising from test results that return after hospital discharge.
                                     
                                                                    - 
                                        
psnet.ahrq.gov/issue/ahrq-national-scorecard-hospital-acquired-conditions-updated-baseline-rates-and-preliminary-0
October 23, 2019 - December 10, 2024 
 
 
 
 
 
 
 
 Inpatient Computerized Provider Order Entry: Findings from the AHRQ … May 1, 2015 
 
 
 
 
 
 
 
 Eliminating CAUTI: Interim Data Report: A National Patient Safety Imperative
                                     
                                                                    - 
                                        
psnet.ahrq.gov/issue/physicians-practice-dispensing-medicines-qualitative-study
November 16, 2022 - October 13, 2015 
 
 
 
 
 
 
 
 Integrating incident data from five reporting systems to assess patient … "Learning by Doing"—resident perspectives on developing competency in high-quality discharge … May 10, 2013 
 
 
 
 
 
 
 
 Perceived causes of prescribing errors by junior doctors in hospital inpatients
                                     
                                                                    - 
                                        
psnet.ahrq.gov/node/33708/psn-pdf
March 01, 2011 - this risk
stratification there's different expectations of the time it will take and the amount of data … In the taxonomy that I have been using, there's extra-hospital
handoffs, like admission, discharge, … need to be the rehash of the entire written
communication, but really focused and targeted for the inpatient … 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.
                                     
                                                                    - 
                                        
psnet.ahrq.gov/issue/surgical-patient-safety-outcomes-critical-access-hospitals-how-do-they-compare
June 05, 2019 - Using data from the  Healthcare Cost and Utilization Project  and American Hospital Association, this … Related Resources 
 
 
 
 
 
 
 Common general surgical never events: analysis of NHS England never event data … the nation's largest military hospital: an analysis of National Surgical Quality Improvement Program data … Association of hospital participation in a surgical outcomes monitoring program with inpatient … April 27, 2015 
 
 
 
 
 
 
 
 Surgeon-specific mortality data disguise wider failings in delivery of
                                     
                                                                    - 
                                        
psnet.ahrq.gov/issue/analysis-iatrogenic-and-hospital-medication-errors-reported-united-states-poison-centers
November 28, 2018 - authors retrospectively reviewed over 99,000  medication errors   reported to the US National Poison Data … by face-to-face feedback to prescribers on adverse drug events recognition and prevention in older inpatients … 2022 
 
 
 
 
 
 
 
 Prevalence and nature of medication errors and medication-related harm following discharge
                                     
                                                                    - 
                                        
psnet.ahrq.gov/primer/patient-safety-indicators
June 15, 2024 - the underlying disease) and that prolonged the hospitalization, produced a disability at the time of discharge … hospitals in identifying these events, which represent opportunities for improvement in the delivery of inpatient … adopted PSI 90 (Patient Safety and Adverse Events Composite) and PSI 04 (Death Rate Among Surgical Inpatients … programs that include: Hospital-Acquired Condition (HAC) Reduction Program  (PSI 90 only) Hospital Inpatient … August 1, 2023 
 
 Sources of nurse-sensitive inpatient safety improvement.
                                     
                                                                    - 
                                        
psnet.ahrq.gov/issue/unintended-harm-associated-hospital-readmissions-reduction-program
August 20, 2018 - The confused and bewildered hospital: adverse event discovery, pay-for-performance, and big data … June 3, 2020 
 
 
 
 
 
 
 
 An organization-specific and modifiable inpatient safety composite measure … May 8, 2019 
 
 
 
 
 
 
 
 Patient safety in inpatient psychiatry: a remaining frontier for health policy
                                     
                                                                    - 
                                        
psnet.ahrq.gov/sites/default/files/2021-09/spotlight_lost_in_transitions_of_care_09.22.2021_final.pdf
January 01, 2021 - – However, her actual discharge prescription, which was not mentioned on 
the discharge summary, was … , the patient was readmitted to the hospital for 
increasing pain and was restarted on her previous inpatient … – The data in PDMPs are state-specific and various settings/organizations in 
addition to hospitals … Providers 
and Settings
34
Clear Communication (1)
• Lack of communication in transitions of care from inpatient … used to create them came from studies of opioid-naïve patients with 
acute pain, while other data came
                                     
                                                                    - 
                                        
psnet.ahrq.gov/issue/automated-identification-extreme-risk-events-clinical-incident-reports
November 03, 2015 - December 31, 2014 
 
 
 
 
 
 
 
 Last orders: follow-up of tests ordered on the day of hospital discharge … October 2, 2013 
 
 
 
 
 
 
 
 Comparison of traditional trigger tool to data warehouse based screening … A multifaceted approach to safety: the synergistic detection of adverse drug events in adult inpatients
                                     
                                                                    - 
                                        
psnet.ahrq.gov/issue/maternal-mortality-near-miss-events-middle-income-countries-systematic-review
October 13, 2021 - The effect of a transitional pharmaceutical care program on the occurrence of ADEs after discharge … by face-to-face feedback to prescribers on adverse drug events recognition and prevention in older inpatients … 2023 
 
 
 
 
 
 
 
 Maternal and Infant Health Inequality: New Evidence from Linked Administrative Data
                                     
                                                                    - 
                                        
psnet.ahrq.gov/issue/how-useful-are-medication-patient-information-leaflets-older-adults-content-readability-and
November 11, 2020 - November 11, 2020 
 
 
 
 
 
 
 
 Medical large language models are vulnerable to data-poisoning attacks … November 1, 2023 
 
 
 
 
 
 
 
 Medication-related clinical decision support alert overrides in inpatients … April 17, 2019 
 
 
 
 
 
 
 
 Medicines-related harm in the elderly post-hospital discharge.
                                     
                                                                    - 
                                        
psnet.ahrq.gov/node/850361/psn-pdf
June 14, 2023 - The results of the echocardiogram were pending on discharge, with anticipation that the
patient’s primary … the unexpected findings, of which potential neoplasms were
discovered in 11%.22 Although no baseline data … extra layer of reinforcement to ensure that primary care
providers close the loop regarding pending inpatient … The safety of inpatient health care. N Engl J Med.
2023;388(2):142-153. [Available at]
5. … Patient safety concerns arising from test results that return after
hospital discharge.
                                     
                                                                    - 
                                        
psnet.ahrq.gov/node/49440/psn-pdf
March 01, 2004 - https://psnet.ahrq.gov/web-mm/autopsy-revelation
The Commentary
The discharge diagnosis of renal colic … In 1994, the last year for which United States data exist, the autopsy rate for all
non-forensic deaths … Example Root Causes of Diagnostic Errors
Human Factors System Factors
Faulty data gathering (eg, incomplete … Inability to access necessary medical information (eg,
outpatient records for hospitalized patients and inpatient … Failure to alter initial
diagnosis when faced with inconsistent results
Poor communication between inpatient
                                     
                                                                    - 
                                        
psnet.ahrq.gov/node/49840/psn-pdf
September 01, 2018 - There is limited data
regarding the frequency of such events with corticosteroids, with literature suggesting … references
https://psnet.ahrq.gov//#references
https://psnet.ahrq.gov//#references
sources of medication data … planning, patient (and family/caregiver)
discharge education, health and general literacy awareness … .(27) Although less well supported by robust
data, an additional area to consider might also be strategies … and span the entire transitional period, relying on the collaboration of
clinical personnel (both inpatient
                                     
                                                                    - 
                                        
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 … 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 … https://psnet.ahrq.gov/issue/national-scorecard-rates-hospital-acquired-conditions-2010-2015-interim-data-national-efforts
                                     
                                                                    - 
                                        
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
                                     
                                                                    - 
                                        
psnet.ahrq.gov/web-mm/deaths-not-foretold-are-unexpected-deaths-useful-patient-safety-signals
March 01, 2004 - death in low-risk DRGs as a 	patient safety indicator is that it can be measured using administrative 	data … fairly substantial differences in safety between hospitals would require 	many years of mortality data … Measures of 	Patient Safety Based on Hospital Administrative Data—The Patient 	Safety Indicators. … from the 			National Inpatient Sample 			 			Excludes patients with any code for cancer, trauma, or … complications 			while in hospital   All discharges with 			disposition of "deceased" per 100 patients with discharge
                                     
                                                                    - 
                                        
psnet.ahrq.gov/issue/dangers-diagnostic-overshadowing
October 26, 2022 - January 2, 2017 
 
 
 
 
 
 
 
 Use of administrative data to find substandard care: validation of the … January 3, 2017 
 
 
 
 
 
 
 
 Identification of in-hospital complications from claims data. … April 24, 2019 
 
 
 
 
 
 
 
 Monitoring the diagnostic process on an inpatient neurology service.
                                     
                                                                    - 
                                        
psnet.ahrq.gov/node/47267/psn-pdf
September 05, 2018 - Extrapolating medication order data
from a random sample of patients at a single academic medical center … over a 1-year period, researchers
estimate that in 2014 there were 29.7 million adult inpatient discharges