-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.332_slideshow.ppt
September 01, 2014 - overdose (the most serious adverse events) may occur in 0.2%–4% of those exposed to opioids in the inpatient … outpatient opioid dose confirmation
Identification of potential addiction/misuse/diversion
PDMPs are state-run … databases that track all pharmacy dispensing of controlled substances
Studies have shown that PDMPs
-
psnet.ahrq.gov/web-mm/bad-writing-wrong-medication
March 01, 2015 - These costs were attributed to inpatient stays (62%), emergency department visits (6%), outpatient care … Characteristics associated with more frequent counseling were younger pharmacists, increased intensity of state … Patient counseling provided in community pharmacies: effects of state regulation, pharmacist age, and … Communication training, adverse events, and quality measures: 2 retrospective database analyses in Washington State
-
psnet.ahrq.gov/primer/failure-rescue
September 15, 2024 - Hospitals with low rates of FTR also reported more inpatient support, higher rates of employing hospitalists … Medicare & Medicaid Services (CMS) and the Leapfrog Group embraced PSI 04 (Death Rate among Surgical Inpatients … This new measure, retitled as “Thirty-day Risk-Standardized Death Rate among Surgical Inpatients with … was endorsed by the Partnership for Quality Measurement (PQM) and recently adopted for Hospital Inpatient
-
psnet.ahrq.gov/node/33782/psn-pdf
March 01, 2015 - to 30 days after admission, on the premise that, as a result of today's short hospital stays, unsafe inpatient … hospital
quality measurement: experience with the Agency for Healthcare Research and Quality (AHRQ) Inpatient … Hospital inpatient mortality. Is it a
predictor of quality? N Engl J Med. 1987;317:1674-1680.
-
psnet.ahrq.gov/web-mm/medical-devices-wild
March 27, 2024 - In medicine there are subscription-based services and publicly available Web-based databases (e.g., MAUDE … October 3, 2013
Work system barriers and facilitators in inpatient care transitions of … September 1, 2007
WebM&M Cases
Impatient Inpatient
-
psnet.ahrq.gov/perspective/implementing-fall-prevention-program
November 29, 2023 - only describe reported falls; under-reporting also has to be factored in.( 4 )
Between 30%–50% of inpatient … Preventing Inpatient Falls
Evidence from community and care home settings cannot be assumed to automatically … apply to hospitals, as inpatients' risk factors are more likely to be connected to acute illness, and … Can volunteer companions prevent falls among inpatients? … Does vitamin D stop inpatients falling? A randomised controlled trial.
-
psnet.ahrq.gov/primer/long-term-care-and-patient-safety
February 24, 2022 - Long-term care settings include skilled nursing facilities (SNFs), inpatient rehabilitation facilities … Inpatient rehabilitation facilities (IRFs) care for patients recovering from surgery, trauma, or an … accreditation programs for nursing care centers that provide post-acute care services, including SNFs and most inpatient … Long-term acute care hospitals and inpatient rehabilitation facilities are accredited in the same fashion … 2023
Patient safety culture in assisted living: staff perceptions and association with state
-
psnet.ahrq.gov/perspective/emergence-trigger-tool-premier-measurement-strategy-patient-safety
May 01, 2012 - been used, including voluntary reports ("incident" or "occurrence" reports), mining of administrative databases … reports are underutilized ( 12-14 ) and only identify between 2% and 8% of all adverse events in the 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 … Certainly the work we did at LDS Hospital shows that if you experience an inpatient adverse drug event
-
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 … been used, including voluntary reports ("incident" or "occurrence" reports), mining of administrative databases … reports are underutilized ( 12-14 ) and only identify between 2% and 8% of all adverse events in the 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
-
psnet.ahrq.gov/node/49840/psn-pdf
September 01, 2018 - State the most common errors made in prescribing corticosteroids. … they are rare,
representing 2% or less of the medication adverse events identified in large national databases … and span the entire transitional period, relying on the collaboration of
clinical personnel (both inpatient
-
psnet.ahrq.gov/perspective/conversation-harlan-krumholz-md-sm
April 01, 2018 - Maybe we were observing that people were going home in a transient state of generalized vulnerability … are commonly cared for by physicians who specialize in treating inpatients. … The discharge summary is a cornerstone of inpatient-to-outpatient provider communication. … Contributing factors to this state—dubbed post-hospital syndrome by Krumholz—include derangement of … Do hospitalist physicians improve the quality of inpatient care delivery?
-
psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge
April 01, 2018 - are commonly cared for by physicians who specialize in treating inpatients. … The discharge summary is a cornerstone of inpatient-to-outpatient provider communication. … Contributing factors to this state—dubbed post-hospital syndrome by Krumholz—include derangement of … Do hospitalist physicians improve the quality of inpatient care delivery? … Maybe we were observing that people were going home in a transient state of generalized vulnerability
-
psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.302_slideshow.ppt
June 01, 2013 - 2
3
Objectives
At the conclusion of this educational activity, participants should be able to:
State … Variation in hospital mortality associated with inpatient surgery.
-
psnet.ahrq.gov/web-mm/are-you-mrs-issue-identification-over-telephone
January 01, 2016 - Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001;285:2114-2120. … 15, 2020
Examining medication ordering errors using AHRQ Network of Patient Safety Databases … February 22, 2023
Cost of inpatient falls and cost-benefit analysis of implementation
-
psnet.ahrq.gov/web-mm/mitigating-risk-intrahospital-transport-pediatric-patients-risk-physiologic-instability
May 27, 2020 - 1, 2012
Community-acquired and hospital-acquired medication harm among older inpatients … and impact of a state-wide medication management intervention.
-
psnet.ahrq.gov/node/49687/psn-pdf
August 21, 2013 - https://psnet.ahrq.gov/web-mm/emergency-error
Case Objectives
State that emergency surgery is high … Variation in hospital mortality associated with inpatient surgery.
-
psnet.ahrq.gov/web-mm/weighty-mistake
September 01, 2016 - Medication errors and adverse drug events in pediatric inpatients. JAMA. 2001;285:2114-2120.
-
psnet.ahrq.gov/web-mm/painful-medication-reconciliation-mishap
May 01, 2008 - Guideline for discharge opioid prescriptions after inpatient general surgical procedures.
-
psnet.ahrq.gov/node/73455/psn-pdf
June 30, 2021 - convened by the Brigham and Women’s Hospital Center for Patient Safety Research and Practice
and the State … With Sex Disparities in Total Joint Arthroplasty Patients and Financial Outcomes from
the National Inpatient
-
psnet.ahrq.gov/sites/default/files/2021-09/spotlight_lost_in_transitions_of_care_09.22.2021_final.pdf
January 01, 2021 - , the patient was readmitted to the hospital for
increasing pain and was restarted on her previous inpatient … • American Society of Hematology’s 2020 guidelines for treating sickle cell
disease state that long-term … – PDMPs do not reflect opioid usage while hospitalized, so these databases
may not be as useful when … – The data in PDMPs are state-specific and various settings/organizations in
addition to hospitals … Providers
and Settings
34
Clear Communication (1)
• Lack of communication in transitions of care from inpatient