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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/node/867672/psn-pdf
February 26, 2025 - operations, severe abdominal pain not responsive to opioid
analgesia (and unresolved at the time of discharge … diagnostic testing results are contradictory, as in this case, the clinician should reassess all
relevant data … the last decade,
observation units have been increasingly utilized to determine a patient’s need for inpatient … [Available
at]
https://psnet.ahrq.gov//mailto:dbarnes@ucdavis.edu
https://www.cdc.gov/nchs/data/nhamcs
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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/web-mm/nstemi-curbside-consultation
August 04, 2021 - The inpatient medicine team obtained a “curbside” cardiology consultation; the consultant felt that her … The patient’s follow-up with cardiology did not occur until two months after discharge. … evaluation, which could have expedited the proper treatment and potentially mitigated a more thorough post-discharge … Integrating Inpatient Electronic Consultations in Cardiology Fellowship. … , 2021
Missed diagnosis of cancer in primary care: insights from malpractice claims data
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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/curated-library/diagnostic-error
March 31, 2025 - of US malpractice claims for diagnostic errors 1986–2010: an analysis from the National Practitioner Data … Characterization of diagnostic error in the hospital setting has traditionally relied on data from autopsy … characterized diagnostic errors among adult patients readmitted to the hospital within 7 days of hospital discharge … In this study, investigators utilized the National Practitioner Data Bank to examine the incidence and … severity of inpatient diagnostic error and estimate the clinical and economic consequences of these
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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/perspective/conversation-withdavid-c-classen-md-ms
May 01, 2012 - Certainly the work we did at LDS Hospital shows that if you experience an inpatient adverse drug event … reports are underutilized ( 12-14 ) and only identify between 2% and 8% of all adverse events in the inpatient … the early days of the patient safety field by highlighting the major patient safety risks present in inpatient … Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001;285:2114-2120. … Rare adverse medical events in VA inpatient care: reliability limits to using Patient Safety Indicators
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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/perspective/risk-management-and-patient-safety
December 01, 2010 - research team reported the incidence of medical errors in the state of New York, based on the hospital discharge … 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 … February 10, 2015
Paid malpractice claims for adverse events in inpatient and outpatient
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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