AHRQ Patient Safety Network

The Collection > Epidemiology of Errors and Adverse Events

PATIENT SAFETY PRIMERS
Never Events
Adverse Events after Hospital Discharge

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•Device-related Complications (69)

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Epidemiology of Errors and Adverse Events

Approach to Improving Safety

•Quality Improvement Strategies (253)

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•Allied Health Services (5)

Target Audience

•Health Care Providers (1023)

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Setting of Care

•Hospitals (986)

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1 - 20 of 1385

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STUDY

The effect of medication reconciliation in elderly patients at hospital discharge.

Midlöv P, Bahrani L, Seyfali M, Höglund P, Rickhag E, Eriksson T. Int J Clin Pharm. 2012;34:113-119.

STUDY

Effectiveness of a pharmacist–nurse intervention on resolving medication discrepancies for patients transitioning from hospital to home health care.

Setter SM, Corbett CF, Neumiller JJ, Gates BJ, Sclar DA, Sonnett TE. Am J Health Syst Pharm. 2009;66:2027-2031.

ORGANIZATIONAL POLICY/GUIDELINES

Using medication reconciliation to prevent errors.

Sentinel Event Alert. January 25, 2006;(35):1-4.

STUDY

Emergency hospitalizations for adverse drug events in older Americans.

Budnitz DS, Lovegrove MC, Shehab N, Richards CL. N Engl J Med. 2011;365:2002-2012.

STUDY

Therapeutic errors involving adults in the community setting: nature, causes and outcomes.

Taylor DM, Robinson J, MacLeod D, MacBean CE, Braitberg G. Aust N Z J Public Health. 2009;33:388-394.

STUDY

Older patients' understanding of emergency department discharge information and its relationship with adverse outcomes.

Hastings SN, Barrett A, Weinberger M, et al. J Patient Saf. 2011;7:19-25.

STUDY

Medical reconciliation in patients discharged from the emergency department.

Sharma AN, Dvorkin R, Tucker V, Margulies J, Yens D, Rosalia A Jr. J Emerg Med. 2012;43:366-373.

STUDY

Medication assessments by care managers reveal potential safety issues in homebound older adults.

Golden AG, Qiu D, Roos BA. Ann Pharmacother. 2011;45:492-498.

STUDY

Patterns in nursing home medication errors: disproportionality analysis as a novel method to identify quality improvement opportunities.

Hansen RA, Cornell PY, Ryan PB, Williams CE, Pierson S, Greene SB. Pharmacoepidemiol Drug Saf. 2010;19:1087-1094.

STUDY

Care homes' use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people.

Barber ND, Alldred DP, Raynor DK, et al. Qual Saf Health Care. 2009;18:341-346.

STUDY

Improving the discharge process by embedding a discharge facilitator in a resident team.

Finn KM, Heffner R, Chang Y, et al. J Hosp Med. 2011;6:494-500.

STUDY

Results of the Medications At Transitions and Clinical Handoffs (MATCH) study: an analysis of medication reconciliation errors and risk factors at hospital admission.

Gleason KM, McDaniel MR, Feinglass J, et al. J Gen Intern Med. 2010;25:441-447.

STUDY

Effect of an electronic medication reconciliation application and process redesign on potential adverse drug events: a cluster-randomized trial.

Schnipper JL, Hamann C, Ndumele CD, et al. Arch Intern Med. 2009;169:771-780.

STUDY

Preventing potentially inappropriate medication use in hospitalized older patients with a computerized provider order entry warning system.

Mattison MLP, Afonso KA, Ngo LH, Mukamal KJ. Arch Intern Med. 2010;170:1331-1336.

STUDY

Prescription and transcription errors in multidose-dispensed medications on discharge from hospital: an observational and interventional study.

Alassaad A, Gillespie U, Bertilsson M, Melhus H, Hammarlund-Udenaes M. J Eval Clin Pract. 2013;19:185-191.

STUDY

The association between transfer of emergency department boarders to inpatient hallways and mortality: a 4-year experience.

Viccellio A, Santora C, Singer AJ, Thode HC Jr, Henry MC. Ann Emerg Med. 2009;54:511-513.

STUDY

Are opioid dependence and methadone maintenance treatment (MMT) documented in the medical record? A patient safety issue.

Walley AY, Farrar D, Cheng DM, Alford DP, Samet JH. J Gen Intern Med. 2009;24:1007-1011.

STUDY

Identifying discrepancies in electronic medical records through pharmacist medication reconciliation.

Stewart AL, Lynch KJ. J Am Pharm Assoc (2003). 2012;52:59-66.

STUDY

The "July phenomenon": is trauma the exception?

Schroeppel TJ, Fischer PE, Magnotti LJ, Croce MA, Fabian TC. J Am Coll Surg. 2009;209:378-384.

COMMENTARY

Medication reconciliation at an academic medical center: implementation of a comprehensive program from admission to discharge.

Murphy EM, Oxencis CJ, Klauck JA, Meyer DA, Zimmerman JM. Am J Health Syst Pharm. 2009;66:2126-2131.

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