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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.137_slideshow.ppt
November 01, 2006 - She reported missing her scheduled hemodialysis session and her symptoms resolved with prompt inpatient … The public release of performance data: what do we expect to gain? A review of the evidence. … Current Measure Set
Heart Attack (Acute Myocardial Infarction or AMI)
• Aspirin at arrival
• Aspirin at discharge … Inhibitor or ARB for left ventricular systolic dysfunction
• Beta Blocker at arrival
• Beta Blocker at discharge … measures validated for one purpose used for another: patient safety indicators derived from administrative data
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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/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/issue/handling-polypharmacy-qualitative-study-using-focus-group-interviews-older-patients-their
August 03, 2022 - August 21, 2024
Clinical impact of medication review and deprescribing in older inpatients … reporting: lessons learned from machine learning analysis of NHS England staff survey and incident data … May 10, 2023
Uptake of pharmacist recommendations by patients after discharge: implementation
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psnet.ahrq.gov/issue/associations-between-internet-based-patient-ratings-and-conventional-surveys-patient
August 26, 2020 - between double-checking and medication administration errors: a direct observational study of paediatric inpatients … November 23, 2016
Hospital readmission and parent perceptions of their child's hospital discharge … 2013
The Patient-Reported Incident in Hospital Instrument (PRIH-I): assessments of data
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psnet.ahrq.gov/web-mm/autopsy-revelation
December 01, 2007 - The Commentary The discharge diagnosis of renal colic in this case almost certainly reflected the operation … 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 … Inability to access necessary medical information (eg, outpatient records for hospitalized patients and inpatient … ask for assistance from a consultant or supervisor when warranted Poor communication between inpatient
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psnet.ahrq.gov/periodic-issue/periodic-issue-469
December 31, 2024 - This study aimed to estimate the prevalence of PIM and PPO at hospital admission and discharge and to … Patients in the intervention group (with pharmacist involvement) had lower rates of PIM at discharge … Using data (including from the Hospital Survey on Patient Safety Culture™ [SOPS®]), this cross-sectional … The potential for bias in artificial intelligence (AI) training data is a well-known problem, but the … challenge of preventing falls and explores strategies for preventing falls and falls with injury in both inpatient
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psnet.ahrq.gov/issue/risk-factors-hospital-admissions-associated-adverse-drug-events
October 18, 2018 - designed to improve medication safety for patients with monitored dosage systems following hospital discharge … 2011
Prevalence, nature, severity and risk factors for prescribing errors in hospital inpatients … December 31, 2014
Validating administrative data for the detection of adverse events
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psnet.ahrq.gov/issue/observational-study-adult-admissions-medical-icu-due-adverse-drug-events
January 28, 2015 - Assessing the use of Google Translate for Spanish and Chinese translations of emergency department discharge … April 8, 2019
Effect of alerts for drug dosage adjustment in inpatients with renal insufficiency … March 10, 2011
A clinical data warehouse-based process for refining medication orders
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psnet.ahrq.gov/issue/shift-change-handovers-and-subsequent-interruptions-potential-impacts-quality-care
February 04, 2009 - by face-to-face feedback to prescribers on adverse drug events recognition and prevention in older inpatients … July 2, 2019
Cost-effective enhancement of claims data to improve comparisons of patient … "It's like two worlds apart": an analysis of vulnerable patient handover practices at discharge
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psnet.ahrq.gov/issue/understanding-preventable-deaths-geriatric-trauma-population-analysis-3452339-patients-center
February 16, 2022 - of a computer-assisted tool with automated electronic integration of population-based community drug data … electronic medication systems in reducing medication error rates and associated harm among hospital inpatients … July 21, 2011
Older patients' understanding of emergency department discharge information
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psnet.ahrq.gov/issue/costs-associated-adverse-drug-events-among-older-adults-ambulatory-setting
May 20, 2020 - 2008
Understanding hazards for adverse drug events among older adults after hospital discharge … by face-to-face feedback to prescribers on adverse drug events recognition and prevention in older inpatients … March 2, 2011
Consistency between coded poison center data and fatality abstract narratives
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psnet.ahrq.gov/issue/electronic-prescribing-and-other-forms-technology-reduce-inappropriate-medication-use-and
August 10, 2022 - by face-to-face feedback to prescribers on adverse drug events recognition and prevention in older inpatients … May 11, 2022
Assessment of requests for medication-related follow-up after hospital discharge … October 28, 2020
A clinical data warehouse-based process for refining medication orders
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psnet.ahrq.gov/issue/analysis-hospital-readmission-rates-after-implementation-hospital-readmissions-reduction
October 12, 2022 - reduce duration and variability in delays to identification of serious injury after falls in hospital inpatients … elderly fallers: identifying associated risk factors for 30-day unplanned readmissions using a clinical data … June 2, 2021
Failure to follow medication changes made at hospital discharge is associated
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psnet.ahrq.gov/issue/alternatives-opioid-education-and-prescription-drug-monitoring-program-cumulatively-decreased
April 06, 2022 - November 4, 2020
Drug-drug interactions and prescription appropriateness at hospital discharge … by face-to-face feedback to prescribers on adverse drug events recognition and prevention in older inpatients … of a computer-assisted tool with automated electronic integration of population-based community drug data
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psnet.ahrq.gov/issue/machine-learning-evaluation-inequities-and-disparities-associated-nurse-sensitive-indicator
July 19, 2023 - March 17, 2021
Medication-related hospital readmissions within 30 days of discharge: … The impact of adding a 2-way video monitoring system on falls and costs for high-risk inpatients … February 1, 2023
Nurse's Achilles Heel: using big data to determine workload factors
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psnet.ahrq.gov/issue/application-human-factors-methods-ensure-appropriate-infant-identification-and-abduction
April 27, 2022 - reduce duration and variability in delays to identification of serious injury after falls in hospital inpatients … respond to errors in their personal health records: mixed methods analysis of cross-sectional survey data … October 20, 2021
Medication errors at hospital admission and discharge: risk factors
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psnet.ahrq.gov/node/72911/psn-pdf
March 15, 2021 - Data
suggests that nurses and pharmacists identify 30% to 70% of medication-ordering errors. … supplements are often overlooked by
providers and patients.7
Medication errors may occur in both inpatient … Inpatient anticoagulation errors
often result in an increased length of stay and greater healthcare … , ensuring access to care after discharge, and post-discharge follow-up. … NCHS Data Brief, no. 347
(August): 1–8.
6.
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psnet.ahrq.gov/node/33574/psn-pdf
March 15, 2025 - the outpatient, or ambulatory care,
setting, efforts to improve safety have mostly focused on the inpatient … Recent data suggests that timely information availability and
managing test results contribute to delayed … designed to assess safety culture in ambulatory
care, and its comparative database (which includes data … information-exchange-among-physicians-caring-same-patient-community
https://psnet.ahrq.gov/primer/readmissions-and-adverse-events-after-discharge
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psnet.ahrq.gov/node/49776/psn-pdf
November 01, 2016 - educational value to trainees and created a system that facilitated poor clinical
performance.(6) Internal data … chance that their patients
received pap smears in the resident clinic approached zero (unpublished data … safety,
the learning environment, and resident–patient relationships, but no actual patient outcomes data … expanded on
Bodenheimer's previously described 10 aspects of high-performing care (engaged leadership, data-driven … Frequent measurement and sharing of data are first
steps to achieving a culture of shared responsibility