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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
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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
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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
*
*
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 … *
*
Take-Home Points (2)
To prevent data entry error of important values such as patient weight
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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.
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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
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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/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.
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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
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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
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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
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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.
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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
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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.
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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
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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
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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/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
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psnet.ahrq.gov/node/49799/psn-pdf
July 01, 2017 - 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/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
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psnet.ahrq.gov/node/49570/psn-pdf
October 01, 2008 - Even in 2008, most practices in the United States continue to use paper-based discharge communication … different health care institutions—primary care physicians may encounter a unique discharge form and … Data clearly show that they want this access, whether they are insured or uninsured (13),
https://psnet.ahrq.gov … best—including the patient, their family, and their
community—is much greater than what can be achieved by an inpatient … the care process and should
be implemented as a part of any health information technology project, inpatient