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psnet.ahrq.gov/issue/responding-safe-care-healthcare-staff-experiences-caring-child-intellectual-disability
June 15, 2022 - March 17, 2021
Inpatient telemedicine and new models of care during COVID-19: hospital … respond to errors in their personal health records: mixed methods analysis of cross-sectional survey data … September 26, 2018
Facilitating Patient Understanding of Discharge Instructions: Workshop
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psnet.ahrq.gov/issue/identifying-potential-prescribing-safety-indicators-related-mental-health-disorders-and
July 22, 2020 - Author(s)
Prevalence and nature of medication errors and medication-related harm following discharge … September 15, 2021
The psychological experiences of nurses after inpatient suicide: a … October 8, 2013
A review of patient safety measures based on routinely collected hospital data
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psnet.ahrq.gov/issue/influencing-culture-quality-and-safety-through-huddles
April 05, 2023 - of a computer-assisted tool with automated electronic integration of population-based community drug data … October 5, 2022
Developing and aligning a safety event taxonomy for inpatient psychiatry … July 13, 2022
Is it time for the mental health field to consider unplanned discharge
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psnet.ahrq.gov/issue/improving-specificity-drug-drug-interaction-alerts-can-it-be-done
September 07, 2022 - of a computer-assisted tool with automated electronic integration of population-based community drug data … April 13, 2022
Impact of clinical decision support therapeutic interchanges on hospital discharge … events by application of a probabilistic, machine-learning based clinical decision support system in an inpatient
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psnet.ahrq.gov/issue/clinical-supervision-general-practice-training-interweaving-supervisor-trainee-and-patient
October 13, 2021 - of a computer-assisted tool with automated electronic integration of population-based community drug data … An analysis of the structure and content of dashboards used to monitor patient safety in the inpatient … December 8, 2021
View More
Related Resources
Danger in discharge
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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/issue/interview-jerry-gurwitz
August 11, 2010 - A conceptual framework for emergency department-to-inpatient handoff negotiations. … May 25, 2005
Guided prescription of psychotropic medications for geriatric inpatients … Project (NAP5) on accidental awareness during general anaesthesia: protocol, methods, and analysis of data … February 27, 2019
Patterns of opioid administration among opioid-naive inpatients and … November 5, 2014
Validating administrative data for the detection of adverse events in
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psnet.ahrq.gov/issue/epidemiology-prescribing-errors-potential-impact-computerized-prescriber-order-entry
May 04, 2010 - January 12, 2022
Developing indicators of inpatient adverse drug events through nonlinear … analysis using administrative data.
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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/periodic-issue/periodic-issue-288
April 28, 2021 - interactions (DDI) among hospitalized older adults taking two or more medications at admission and discharge … CDS as “systems that can learn and change performance over time, incorporate new clinical evidence, data … types, data sources, and methods for interpreting data.” … insulin but thought the patient did not meet criteria for diabetic ketoacidosis (DKA), but after three inpatient … patient was admitted for scheduled Cesarean delivery, before being tested according to a universal inpatient
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psnet.ahrq.gov/periodic-issue/periodic-issue-324
January 07, 2022 - This study explored administrator, physician, nurse, and caregiver perceptions of safety in pediatric inpatient … Participants reported changes in workflows, discharge and transfer process, patient and family engagement … Using data from the Healthy Work Place trial, this study explored characteristics associated with high … The psychiatry team recommended discharge with outpatient therapy; he was discharged with outpatient … He was taken to the ED for a third time, where has was evaluated and involuntarily admitted to an inpatient
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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/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/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/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/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/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/node/49518/psn-pdf
August 01, 2006 - 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. … Available at:
http://www.cdc.gov/nchs/data/ad/ad374.pdf
http://www.census.gov/prod/2005pubs/06statab
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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/medical-errors-reported-french-general-practitioners-training-results-survey-and-individual
March 10, 2011 - Related Resources From the Same Author(s)
Effect of alerts for drug dosage adjustment in inpatients … January 28, 2015
A clinical data warehouse-based process for refining medication orders