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psnet.ahrq.gov/perspective/balancing-supervision-and-autonomy-ongoing-tension
February 01, 2012 - patients shift-to-shift independently by the middle of their intern year but not to coordinate a complex discharge … How residents view their clinical supervision: a reanalysis of classic national survey data. … In many teaching hospitals, the hospitalist program has replaced the role of the inpatient ward attendings … In the past, hundreds of attending physicians who only occasionally took care of inpatients were a very … The number of minor mistakes is increased slightly, but the data also shows that the overall care of
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psnet.ahrq.gov/perspective/patient-engagement-and-patient-safety
February 01, 2013 - health records, patients and families should have access to the daily recording of care and have a discharge … because accurate useful information is not given to the patient, family, and the community provider at discharge … Do you think that public reporting of those data and having those data influence your payments are good … What does the data mean? … , 2011
Confidential clinician-reported surveillance of adverse events among medical inpatients
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psnet.ahrq.gov/web-mm/management-cardiac-arrest-unconventional-locations
June 14, 2023 - additional tools and resources designed to facilitate the efficient capture, analysis, and reporting of data … from inpatient cardiac arrests. … The data from these registries have been the driving force behind changes to responses and processes … WebM&M Cases
Home Medications Contribute to a Unique Opportunity for Error on Discharge … January 19, 2022
A conceptual framework to reduce inpatient preventable deaths.
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psnet.ahrq.gov/issue/communication-medical-product-risk-how-effective-effective-enough
January 17, 2007 - February 24, 2016
A trigger tool to detect harm in pediatric inpatient settings. … the nation's largest military hospital: an analysis of National Surgical Quality Improvement Program data … Hospital Readmissions and Improve Health Outcomes
March 29, 2023
Hospital discharge
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psnet.ahrq.gov/web-mm/diagnosing-hiv-it-doesnt-take-brain-surgeon
January 01, 2018 - and high-risk populations with high rates of testing.( 17-19 ) In the absence of direct clinical data … prevalence-based testing is often unfeasible because many clinicians do not have access to local prevalence data … In the inpatient setting, protocols for routinely identifying previous HIV test results upon admission … Identifying undiagnosed human immunodeficiency virus: the yield of routine, voluntary inpatient testing … 2012
WebM&M Cases
Treatment Challenges After Discharge
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psnet.ahrq.gov/perspective/how-does-infection-prevention-fit-safety-program
March 01, 2014 - The expansive role of infection prevention in inpatient and outpatient settings has resulted in the establishment … Leadership Needed from HHS to Prioritize Prevention Practices and Improve Data on These Infections. … Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital … You need to be able to provide individual level feedback and data. … Effect of a pharmacist intervention on clinically important medication errors after hospital discharge
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psnet.ahrq.gov/periodic-issue/periodic-issue-305
August 25, 2021 - Patient safety organizations (PSOs) collect and analyze protected safety incident data from across the … Based on inpatient electronic health record data between March 1 and April 20 of 2020, this cohort study … Based on multi-year data from one health system, the authors of this cohort study found that black women … Patient safety organizations (PSOs) collect and analyze protected safety incident data from across the
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.332_slideshow.ppt
September 01, 2014 - Co-morbidity and utilization of medical services by pain patients receiving opioid medications: data … Clinical application of opioid equianalgesic data. … overdose (the most serious adverse events) may occur in 0.2%–4% of those exposed to opioids in the inpatient … Cost and quality implications of opioid-based postsurgical pain control using administrative claims data … Cost and quality implications of opioid-based postsurgical pain control using administrative claims data
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psnet.ahrq.gov/node/846564/psn-pdf
March 29, 2023 - Services (CMS) started requiring hospitals to use the SAFER guides as part of the
FY 2022 Hospital Inpatient … that it was cost-effective and detailed implementation lessons learned drawn from the
qualitative data … For example, if users
are required to enter data in multiple places or prompted to enter data that are … AI and machine learning use algorithms to absorb large amounts of
historical and real-time data and … then predict outcomes and recommend treatment options as new data are
entered by clinicians.
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psnet.ahrq.gov/web-mm/postpartum-woman-erroneous-sars-cov-2-test
December 23, 2020 - admitted in March 2020 for a scheduled Cesarean delivery, before being tested according to a universal inpatient … Two days after the mother’s discharge, the commercial and state lab tests were both reported as negative … related diagnosis of COVID-19 has been difficult because of RT-PCR’s limited sensitivity. 19 - 29 Pooled inpatient … A systematic review of individual participant data. … Covid-19: Lateral flow tests miss over half of cases, Liverpool pilot data show.
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psnet.ahrq.gov/node/73202/psn-pdf
April 28, 2021 - admitted in March 2020 for a scheduled Cesarean delivery, before being
tested according to a universal inpatient … https://psnet.ahrq.gov/web-mm/postpartum-woman-erroneous-sars-cov-2-test
Two days after the mother’s discharge … related diagnosis of
COVID-19 has been difficult because of RT-PCR’s limited sensitivity.19-29 Pooled inpatient … A systematic review of individual participant data. … Covid-19: Lateral flow tests miss over half of cases, Liverpool pilot data show.
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psnet.ahrq.gov/node/50843/psn-pdf
January 29, 2020 - He was eventually
discharged to an inpatient alcohol use disorder treatment center. … Use of Hypertonic Saline
Data regarding treatment strategies for management of severe hyponatremia are
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psnet.ahrq.gov/node/49854/psn-pdf
February 01, 2019 - being underreported, diagnostic error is common (1), occurring in 5%–20% of emergency
department, inpatient … Sentinel Event Data—Event Type by Year. The Joint Commission. [Available at]
9.
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psnet.ahrq.gov/node/49778/psn-pdf
December 01, 2016 - She reviewed the laboratory data and was surprised to find that the
patient had no positive blood cultures … a core component of a stewardship program.(4) In a typical prospective
audit and feedback program, inpatient … Standalone EHRs are available, but extensive time and expense are necessary for
interface development and data
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psnet.ahrq.gov/web-mm/limb-loss-after-vasopressor-use
March 14, 2012 - consistently demonstrated improved mortality or hospital length of stay. 29 The EHR not only includes data … Proposed solutions vary widely and include increasing hospital inpatient staffing and bed space, expanding … outpatient services, improving ED diagnostic pathways, and expediting hospital discharge, among others … Association of an emergency department-based intensive care unit with survival and inpatient intensive
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psnet.ahrq.gov/node/846975/psn-pdf
March 28, 2023 - Review Committee (MMRC)
data or use national MMRC data published by the Centers for Disease Control … We now have bundles on topics such as postpartum discharge and care for pregnant and
postpartum patients … For example, we do not have
a lot of inpatient facilities that allow for co-admission of a parent who … We are fortunate to have a whole AIM data and evaluation team
and data visualization center to support … The challenges surrounding data availability is a factor in the AIM Program’s data management plans.
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psnet.ahrq.gov/sites/default/files/2023-09/a_missed_bowel_perforation_-_the_importance_of_diagnostic_reasoning.pdf
January 01, 2023 - In this case, anchoring on fluid overload or heart failure likely led to neglecting nonconforming
data … However, a lactate level >2mmol/L in the setting of sepsis is associated with
increased risk of inpatient … in every 3 hospital deaths are associated with sepsis,
which continues to be the leading cause of inpatient … should be
used in conjunction with bedside markers and laboratory assessments, not in lieu
of those data … Incidence and Trends of Sepsis in US Hospitals Using Clinical vs Claims Data, 2009-2014.
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psnet.ahrq.gov/web-mm/too-many-cooks-kitchen
March 07, 2018 - creatinine, diabetes, history of stroke or transient ischemic attack, and emergency surgery. 20 Substantial data … requiring an in-person visit by the attending anesthesiologist or primary team physician prior to PACU discharge … November 16, 2015
Discharge rounds in the 80-hour workweek: importance of the trauma … Tooth
August 21, 2007
WebM&M Cases
Impatient Inpatient
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psnet.ahrq.gov/web-mm/misdiagnosis-small-bowel-obstruction-setting-previous-abdominal-operations
September 27, 2023 - 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
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psnet.ahrq.gov/node/33858/psn-pdf
May 01, 2018 - Here are the data elements that the doctor has to collect. … Switching is hard and may require
a lot of manual data entry. … I spend $2 million per year providing inpatient, outpatient, emergency department, and urgent care clinical … care management, population
health, data visualizations, etc. … exchanges and guarantee
the integrity of those data exchanges?