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psnet.ahrq.gov/perspective/conversation-georgia-galanou-luchen-pharm-d
October 24, 2021 - Residents usually train in a hospital or health-system environment, providing inpatient and outpatient … The team also participates in quality reviews, looking at where errors happened, and collecting data … process, the inpatient providers may have an incomplete history of the patient’s existing prescriptions … In addition, medications that may have been appropriate during the inpatient stay, but inappropriate … Impact of community pharmacist-performed post-discharge medication reviews in transitions of care.
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psnet.ahrq.gov/node/33675/psn-pdf
October 01, 2008 - It is unlikely that this can be done
with only administrative data. … Administrative data based patient safety research: a critical review. … Present on Admission (POA) Indicator Reporting by Acute Inpatient Prospective Payment System (IPPS) … Available at: https://leapfroggroup.org/data-
users/leapfrog-hospital-survey
11. … Acquired conditions: an improvement to hospital
discharge abstracts.
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psnet.ahrq.gov/perspective/measuring-and-responding-deaths-medical-errors
April 01, 2008 - It is problematic to extrapolate from such small numbers of deaths to an estimate of inpatient mortality … treating clinicians) and can detect potential causative factors that were not identified through other data … Even academic hospitals now perform autopsies on fewer than 10% of inpatient deaths; a recent British … almost exclusively used to analyze deaths while patients are hospitalized, or shortly after hospital discharge … 2017
National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015: Interim Data
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psnet.ahrq.gov/sites/default/files/2020-10/final_slides_oct_2020_spotlight_case_inpt_stroke_mngt_in_adolescent_with_type1_diabetes.pdf
January 01, 2020 - • Newer insulin pumps can receive data from CGMs and employ
automated algorithms (called “hybrid closed-loop … favor continuing these
technologies in the hospital, but potential for errors will increase if
data … cannot be accessed or understood by inpatient medical teams. … Patient Self-Management of Diabetes Care in the Inpatient Setting: Con. … Consensus Statement on Inpatient Use of Continuous Glucose
Monitoring.
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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/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/its-all-syringe
February 01, 2013 - 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. … , 2011
Confidential clinician-reported surveillance of adverse events among medical inpatients
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psnet.ahrq.gov/perspective/wild-west-patient-safety-office-based-anesthesia
April 01, 2003 - The basic hospital requirement that a responsible adult accompany the patient at discharge is not consistently … Reports of several patient injuries following early discharge suggest that postoperative complications … enforced.( 14 - 19 )
The field of anesthesiology has long been a front-runner in patient safety in the inpatient … office-based settings to provide the same level of protection for patients that they enjoy and expect in the inpatient … January 12, 2011
Adverse event reporting: lessons learned from 4 years of Florida office data
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psnet.ahrq.gov/issue/can-preventable-adverse-events-be-predicted-among-hospitalized-older-patients-development-and
March 18, 2013 - by face-to-face feedback to prescribers on adverse drug events recognition and prevention in older inpatients … May 1, 2015
Adverse drug events after hospital discharge in older adults: types, severity … Adverse drug reactions and therapeutic errors in older adults: a hazard factor analysis of poison center data
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psnet.ahrq.gov/perspective/conversation-david-meltzer-md-phd
November 01, 2018 - When I came to Chicago as a new faculty member, I started collecting data on the inpatient services, … Are there empirical data to help answer those questions? … DM : We don't have a lot of data right now and we need a lot more. … Hospitals and physician groups faced new pressures to manage inpatients efficiently. … View
November 1, 2018
Promoting effective transitions of care at hospital discharge
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psnet.ahrq.gov/perspective/comprehensivist-model-care-hospitalists-view
November 01, 2018 - Hospitals and physician groups faced new pressures to manage inpatients efficiently. … When I came to Chicago as a new faculty member, I started collecting data on the inpatient services, … Are there empirical data to help answer those questions? … DM : We don't have a lot of data right now and we need a lot more. … PhD
November 1, 2018
Promoting effective transitions of care at hospital discharge
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psnet.ahrq.gov/node/49563/psn-pdf
May 01, 2008 - overcrowding, and hospitals operating at full capacity often
result in increased waiting time for inpatient … Finally,
factors such as inadequate systems for triaging and observing patients awaiting an inpatient … , RN assessment, IV placement, phlebotomy) even before a bed becomes available, and (iii) help the
inpatient … systematic review revealed the frequent failure of
information transfer that occurs during hospital discharge … For the hospitalist, lack
of access to outpatient clinic notes, labs, and other significant data impedes
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psnet.ahrq.gov/issue/transition-new-electronic-health-record-and-pediatric-medication-safety-lessons-learned
April 12, 2011 - This pre–post study examined changes in medication errors for pediatric inpatients following implementation … , 2017
Improving communication with primary care physicians at the time of hospital discharge … July 7, 2010
The impact of electronic medical records data sources on an adverse drug
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psnet.ahrq.gov/node/33705/psn-pdf
January 01, 2011 - research team reported the incidence of medical errors in the state of New York,
based on the hospital discharge … analysis of 30,121 cases.(1) While this comprehensive study provided key
data about the problem of … Using medical malpractice claims data to reduce surgical risk and improve
patient safety. … A policy-based intervention for the reduction of
communication breakdowns in inpatient surgical care … The following will be discussed with and approved by the attending before they occur:
Discharge from
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psnet.ahrq.gov/web-mm/impact-communication-medication-errors
August 01, 2009 - 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 costs … , ensuring access to care after discharge, and post-discharge follow-up. … NCHS Data Brief, no. 347 (August): 1–8.
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psnet.ahrq.gov/web-mm/glucose-roller-coaster
February 02, 2022 - physicians other than those primarily responsible, and the limitations of "signout," the transfer of patient data … The attending could invest time teaching the interns involved about inpatient problem triage and proper … easily accessible medical record, and computerized physician order entry—can improve the quality of data … Residents can also transmit requests to schedule tests or discharge appointments to ward clerks. … Tools of continuity: the content of inpatient check-out lists [Abstract].
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psnet.ahrq.gov/perspective/weekend-effect-cardiology-it-real-if-so-can-it-be-fixed
June 01, 2017 - One study, using data from Nationwide Inpatient Sample (a 20% representative sample of all nonfederal … PA : Well, it's blurring this distinction between clinical data and administrative data. … We're beginning to use some of that data linked to hospital data to learn more about the patient journey … November 16, 2022
Patient Safety Primers
Inpatient … December 2, 2020
Patient Safety Primers
Discharge Planning
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psnet.ahrq.gov/node/49508/psn-pdf
January 01, 2007 - 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 … and procedures revealed no statutes that expressly
prohibit collection of patients' primary language data … Racial, Ethnic and Primary Language Data Collection: An Assessment of
Federal Policies, Practices and
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psnet.ahrq.gov/web-mm/dangerous-dapsone
January 10, 2011 - Of note, on admission, the inpatient pharmacy had called the admitting team about the inappropriately … Third, despite an intervention attempt by the inpatient pharmacist, the house staff incorrectly ordered … Pharmacists should not dispense any drug based on a prescription without data that support its use in … When possible, pharmacists should be provided patient data related to the medications they are asked … Same Author(s)
Transition of care for hospitalized elderly patients—development of a discharge
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psnet.ahrq.gov/web-mm/dressed-failure
September 01, 2011 - On the one hand, transmission of poor quality data perpetuates poor quality data into the new EHR. … , laboratory data, imaging files, clinical documentation, discharge summaries, and transcriptions of … Unlike narrative or free text data, structured data is captured in discrete fields, is readable by the … Unit-based clinical pharmacists' prevention of serious medication errors in pediatric inpatients … October 1, 2008
WebM&M Cases
Discharge Fumbles