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psnet.ahrq.gov/perspective/conversation-withgeri-amori-phd
December 01, 2010 - research team reported the incidence of medical errors in the state of New York, based on the hospital discharge … The immediate response was to convene clinical leaders and to review the claims and data with them. … 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/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/web-mm/procedure-complications-who-responsible-follow
July 31, 2023 - recommendations were communicated by the thoracic surgery team, in part because there was no active inpatient … (23% versus 45%), and a 35% decrease in mean length of hospital stay (13 versus 20 days). 5 These data … associated with improved clinical outcomes in benign esophageal perforation: an individual patient data … WebM&M Cases
Be Picky about your PICCs—Fragmented Care and Poor Communication at Discharge
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psnet.ahrq.gov/sites/default/files/2024-10/spotlight_case_a_cognitive_and_communication_blind_spot_slides.pptx
January 01, 2024 - and decompression but had persistent virtually complete paralysis below the C7 level upon hospital discharge … permanent paralysis
THE COMMENTARY
Garth Utter, MD, MSc, FACS
9
9
Overview
10
Overview (1)
Modern inpatient … Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-Motion … Thromboembolism after trauma: an analysis of 1602 episodes from the American College of Surgeons National Trauma Data
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www.ahrq.gov/sites/default/files/2025-06/dean-report.pdf
January 01, 2025 - feedback of utilization data. Upon completion of the 1-year pilot deployment that! … more than six million cases annually, one million
hospitalizations, and over $7 billion dollars for inpatient … For example, data
indicate that approximately 27% of all emergency department visits could take place … evaluation will decrease by ≥ 3% in the ePneumonia
cluster, replaced by more direct hospital admissions or discharge … , plus respiratory chief complaint and data from the
respiratory questionnaire form, as well as age
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/mental-illness-outcomes_disposition-comments.pdf
January 15, 2015 - Importantly, inpatient hospitalization for SMI has been
recognized as one of the major cost contributors … We recommend AHRQ to include literature
of costs of inpatient hospitalizations among SMI (p.1). … On page 13, patient involvement in treatment should
include both inpatient treatment AND outpatient … the approach of the Joint
Commission and other regulatory bodies is that any suicide
shortly after discharge … provider
could be the one penalized, even if they were more efficient
than the prior provider who didn’t discharge
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digital.ahrq.gov/sites/default/files/docs/publication/uc1hs014920-bellamy-final-report-2007.pdf
January 01, 2007 - were requested from the WV Health Care Authority
in 2005 (for 2004 data) and in 2006 (for 2005 data … The data were cleaned and the AHRQ PSI
program run to generate state-specific data. … over a given period of time in the
voluntary system (ORM), compared to an extensive chart review for inpatient … , either your own or grouped data? … One participating CAH merged with a
larger hospital and no longer had inpatient beds.
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www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-harms.pdf
August 01, 2025 - Diego,
California
R18 HS020594
[Grant]
Innovations Reducing
Hyper- and Hypo-
Glycemic Events in
Inpatients … patients had lower in-hospital mortality than other groups, many still experienced
severe disability at discharge … Post-discharge care accounted for a large proportion of variation in payments
for all four procedures … 75Q80124F32009
[Contract]
MHS IV: Interventions to
Prevent Non-Ventilator-
Associated Pneumonia for
Inpatients … synthesis evaluated interventions to
prevent non-ventilator hospital-acquired pneumonia (NV-HAP) in adult inpatients
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hcup-us.ahrq.gov/db/nation/neds/stats/NEDS_2010_MaskedStats_Core.PDF
January 01, 2010 - please refer to the section on Description of Data Elements. … For more information about the coding of HCUP data elements,
HCUP Summary Statistics Report: NEDS 2010 … section on Description of Data Elements. … 1.57
DISP_ED : Disposition of patient (uniform) from ED 28,584,301 0 1.00 99.00 2.65 5.72
DQTR : Discharge … 284,740 1.00
6: Home health care 20,927 0.07
7: Against medical advice 375,260 1.31
9: Admitted as an inpatient
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www.ahrq.gov/patient-safety/settings/labor-delivery/perinatal-care/modules/teamwork/pf-engagement-fac-guide.html
July 01, 2023 - Involving patients and families in discharge planning and plans for safe care at home. … It should track, trend, and analyze necessary data for quality assurance and other identified purposes
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/mhs-IV-rapid-response-surgical-report-cards.pdf
November 01, 2023 - The indicators most
relevant to surgery are:
• PSI 04 – Death rate among surgical inpatients with … Comparative Analysis of Perioperative
Outcomes Using Nationally Derived Hospital Discharge Data Relative … A National Database Analysis Comparing the
Nationwide Inpatient Sample and American College of Surgeons … hospitals
Cases: 2,957 surgeries
Increase pre-op statin use
(58.87% to 71.81%;
p=0.0082), increase
discharge … 80.37%; p=0.0037);
increase pre-op antiplatelet
use (60.8% to 78.38%;
p<0.0001), and increased
discharge
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psnet.ahrq.gov/web-mm/delay-appropriate-diagnosis-and-treatment-leading-death-pulmonary-embolism
December 31, 2024 - delay in diagnosis, the radiologist did not convey critical findings from the chest CT angiogram to the inpatient … an elevated lactic acid along with other signs of cardiogenic shock, which should have alerted the inpatient … with critical findings, the reporting radiologist did not call the clinician for 24 (35%). 39 While inpatient … Clinicians are responsible for appropriate communication and review of all available data to maximize … May 1, 2011
WebM&M Cases
Discharge Fumbles
-
www.ahrq.gov/hai/cusp/clabsi-final-companion/clabsicompapc.html
January 01, 2013 - Data Interpolation Example
Appendix E. Moderating Factors Flowchart
Appendix F. … before 2002
CDC,
1998
National Nosocomial Infections Surveillance (NNIS) system report, data … 2005
Excess mortality, hospital stay, and cost due to candidemia: A case-control study using data … Published before 2002
Parodi S,
2001
Early switch and early discharge opportunities in intravenous … to clinical and financial hospital data to estimate increased length of stay and healthcare costs.
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/pdi/d4h_pdi10-sepsis-bestpractices.pdf
May 17, 2016 - providers, respiratory therapists, dietitians, and
pharmacists from infection control, intensive care, and inpatient … • Use a systemwide mechanism to share data with administrators, providers, and staff, such as
a sepsis
-
psnet.ahrq.gov/node/49659/psn-pdf
July 01, 2012 - database trumps narrative in new media.(17) Current trainees are comfortable importing large
chunks of data … An educational intervention to improve residents' inpatient charting.
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.179_slideshow.ppt
July 01, 2008 - Emergency Department Data From the Drug Abuse Warning Network: Final Estimates 1995-2002. … Heroin detoxification with buprenorphine on an inpatient psychiatric unit.
-
psnet.ahrq.gov/node/49821/psn-pdf
February 01, 2018 - drawers,
and systems that utilize barcoding technology.(2) This rise in ADC utilization is driven by the data … Medication errors and adverse drug events in pediatric
inpatients. JAMA. 2001;285:2114-2120.
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psnet.ahrq.gov/web-mm/hemolysis-holdup
July 03, 2016 - Clinicians must rely on their assessment of the patient's condition and other data to care for the patient … Related Resources From the Same Author(s)
A trigger tool to detect harm in pediatric inpatient
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4v_combo_pdi10-sepsis-bestpractices.pdf
May 17, 2016 - providers, respiratory therapists, dietitians, and
pharmacists from infection control, intensive care, and inpatient … • Use a systemwide mechanism to share data with administrators, providers, and staff, such as
a sepsis
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/combined/d4i_combo_psi12-dvt-bestpractices.pdf
May 20, 2016 - o Use reliable data collection and performance tracking. … Hospital Inpatient Quality Reporting (IQR) Program measures (calendar year 2014
discharges).