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441. Measuring Patient Safety | PSNet
     psnet.ahrq.gov/perspective/measuring-patient-safety
     December 14, 2022 - This transition has also facilitated the shift from process measures to outcome measures. … Strategy , CMS emphasizes the need to promote safety and highlights its continued focus on the ongoing transition … Prior work focused on patient safety measurement, including the transition to digital measures, will … This also allows the transition from primarily chart-abstracted or claims-based measures to including

442. In Conversation With... Dr. Michelle Schreiber on Measuring Patient Safety | PSNet
     psnet.ahrq.gov/perspective/conversation-dr-michelle-schreiber-measuring-patient-safety
     December 14, 2022 - This also allows the transition from primarily chart-abstracted or claims-based measures to including … This transition has also facilitated the shift from process measures to outcome measures. … Strategy , CMS emphasizes the need to promote safety and highlights its continued focus on the ongoing transition … Prior work focused on patient safety measurement, including the transition to digital measures, will

443. Medication Reconciliation | PSNet
     psnet.ahrq.gov/primer/medication-reconciliation
     March 15, 2025 - Medication Reconciliation Citation Text: Medication Reconciliation. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId R…

444. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/33604/psn-pdf
     December 15, 2024 - Pharmacist's Role in Medication Safety December 15, 2024 The Pharmacist's Role in Medication Safety. PSNet [internet]. 2019. https://psnet.ahrq.gov/primer/pharmacists-role-medication-safety PSNet primers are regularly reviewed and updated by the UC Davis PSNet Editorial Team to ensure that they reflect current res…

445. Communication Failure—Who's in Charge? | PSNet
     psnet.ahrq.gov/web-mm/communication-failure-whos-charge
     April 01, 2018 - Failure of this transition of roles and care can impair care and communication moving forward, as it … At the moment of this first transition of care (i.e., the OR to the ICU), the surgeon clearly has the

446. Using medication containers during pharmacist transitional care visits and impact on medication discrepancies identified and hospital readmission risk. | PSNet
     psnet.ahrq.gov/issue/using-medication-containers-during-pharmacist-transitional-care-visits-and-impact-medication
     March 08, 2023 - Study Using medication containers during pharmacist transitional care visits and impact on medication discrepancies identified and hospital readmission risk. Citation Text: Herges JR, Garrison GM, Mara KC, et al. Using medication containers during pharmacist transitional care visits and …

447. Longitudinal medication reconciliation at hospital admission, discharge and post-discharge. | PSNet
     psnet.ahrq.gov/issue/longitudinal-medication-reconciliation-hospital-admission-discharge-and-post-discharge
     August 19, 2020 - Study Longitudinal medication reconciliation at hospital admission, discharge and post-discharge. Citation Text: Daliri S, Bouhnouf M, van de Meerendonk HWPC, et al. Longitudinal medication reconciliation at hospital admission, discharge and post-discharge. Res Social Adm Pharm. 2020;17(…

448. Re-Engineered Discharge (RED) Toolkit. | PSNet
     psnet.ahrq.gov/issue/re-engineered-discharge-red-toolkit
     June 20, 2014 - Toolkit Re-Engineered Discharge (RED) Toolkit. Citation Text: Re-Engineered Discharge (RED) Toolkit. Jack B, Paasche-Orlow M, Mitchell S, Forsythe S, Martin J. Rockville, MD: Agency for Healthcare Research and Quality; September 2015. AHRQ Publication No. 12(13)-0084. Copy Citation …

449. Estimating the impact on patient safety of enabling the digital transfer of patients' prescription information in the English NHS. | PSNet
     psnet.ahrq.gov/issue/estimating-impact-patient-safety-enabling-digital-transfer-patients-prescription-information
     May 24, 2023 - Study Estimating the impact on patient safety of enabling the digital transfer of patients' prescription information in the English NHS. Citation Text: Camacho EM, Gavan S, Keers RN, et al. Estimating the impact on patient safety of enabling the digital transfer of patients’ prescription…

450. Measuring the impact of medication-related interventions on 30-day readmission rates in a skilled nursing facility. | PSNet
     psnet.ahrq.gov/issue/measuring-impact-medication-related-interventions-30-day-readmission-rates-skilled-nursing
     July 29, 2020 - Study Measuring the impact of medication-related interventions on 30-day readmission rates in a skilled nursing facility. Citation Text: Amin PB, Bradford CD, Rizos AL, et al. Measuring the Impact of Medication-Related Interventions on 30-Day Readmission Rates in a Skilled Nursing Facili…

451. A new professionalism? Surgical residents, duty hours restrictions, and shift transitions. | PSNet
     psnet.ahrq.gov/issue/new-professionalism-surgical-residents-duty-hours-restrictions-and-shift-transitions
     October 19, 2022 - Study A new professionalism? Surgical residents, duty hours restrictions, and shift transitions. Citation Text: Coverdill JE, Carbonell AM, Fryer J, et al. A new professionalism? Surgical residents, duty hours restrictions, and shift transitions. Acad Med. 2010;85(10 Suppl):S72-5. doi:1…

452. The Lost Start Date: an Unknown Risk of E-prescribing | PSNet
     psnet.ahrq.gov/web-mm/lost-start-date-unknown-risk-e-prescribing
     December 02, 2020 - for the first 3 weeks (based on the higher risk of recurrence during this initial period), and then transition … mentioned that this error occurred in the context of two high-risk clinical domains: anticoagulation and transition

453. Delay in Malignancy Diagnosis Reflects Systemic Failures | PSNet
     psnet.ahrq.gov/web-mm/delay-malignancy-diagnosis-reflects-systemic-failures
     September 25, 2019 - Patient Care Handoffs All pathology groups must have clear policies and procedures surrounding the transition … Transition to subspecialty sign-out at an academic institution and its advantages.

454. A framework for the analysis of communication errors in health care. | PSNet
     psnet.ahrq.gov/issue/framework-analysis-communication-errors-health-care
     October 21, 2020 - Commentary A framework for the analysis of communication errors in health care. Citation Text: Bender JA, Thiyagarajan S, Morrish W, et al. A framework for the analysis of communication errors in health care. J Patient Saf. 2025;21(2):69-81. doi:10.1097/pts.0000000000001303. Copy Citat…

455. Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention | PSNet
     psnet.ahrq.gov/web-mm/correct-treatment-plan-incorrect-diagnosis-pharmacist-intervention
     May 01, 2011 - Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention Citation Text: Nelson SD. Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2017. Cop…

456. Handoffs | PSNet
     psnet.ahrq.gov/primer/handoffs
     October 18, 2023 - Handoffs Citation Text: Handoffs and Signouts. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2019. Copy Citation Format: Google Scholar BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS Download…

457. I-PASS handoff program: use of a campaign to effect transformational change. | PSNet
     psnet.ahrq.gov/issue/i-pass-handoff-program-use-campaign-effect-transformational-change
     April 24, 2018 - Study I-PASS handoff program: use of a campaign to effect transformational change. Citation Text: Rosenbluth G, Destino LA, Starmer AJ, et al. I-PASS Handoff Program: Use of a Campaign to Effect Transformational Change. Ped Qual Saf. 2018;3(4):e088. doi:10.1097/pq9.0000000000000088. Co…

458. Assessment of patient retention of inpatient care information post-hospitalization. | PSNet
     psnet.ahrq.gov/issue/assessment-patient-retention-inpatient-care-information-post-hospitalization
     June 01, 2022 - Study Assessment of patient retention of inpatient care information post-hospitalization. Citation Text: Townshend R, Grondin C, Gupta A, et al. Assessment of patient retention of inpatient care information post-hospitalization. Jt Comm J Qual Patient Saf. 2023;49(2):70-78. doi:10.1016/j…

459. Medication Reconciliation: Whose Job Is It? | PSNet
     psnet.ahrq.gov/web-mm/medication-reconciliation-whose-job-it
     May 01, 2018 - Case Objectives Appreciate the prevalence and impact of medication discrepancies at times of transition … after the hospital stay often becomes a point of confusion for patients and clinicians during care transition

460. The Safety and Quality of Long Term Care | PSNet
     psnet.ahrq.gov/web-mm/safety-and-quality-long-term-care
     January 01, 2016 - Finally, nursing home residents frequently transition between settings. … Perhaps better communication across settings during points of transition could have reduced the resident's