Deficits in discharge documentation in patients transferred to rehabilitation facilities on anticoagulation: results of a systemwide evaluation.

Esteban Gandara; Thomas T Moniz; Jonathan Ungar; Jason Lee; Myrna Chan-Macrae; Terrence O'Malley; Jeffrey L Schnipper

Study

Deficits in discharge documentation in patients transferred to rehabilitation facilities on anticoagulation: results of a systemwide evaluation.

August 6, 2008

Gandara E, Moniz TT, Ungar J, et al. Jt Comm J Qual Patient Saf. 2008;34(8):460-3.

View more articles from the same authors.

Many patients discharged from hospitals on anticoagulant medications (including warfarin and heparin) lacked adequate documentation of the duration of therapy and monitoring needs. Ensuring the safety of anticoagulant therapy is a Joint Commission National Patient Safety Goal.

PubMed citation

Available at

Free full text

Related Resources From the Same Author(s)

Communication and information deficits in patients discharged to rehabilitation facilities: an evaluation of five acute care hospitals.

October 28, 2009

Addition of electronic prescription transmission to computerized prescriber order entry: effect on dispensing errors in community pharmacies.

February 2, 2011

Single-parameter early warning criteria to predict life-threatening adverse events.

June 23, 2010

The problem with medication reconciliation.

August 31, 2016

Association of a web-based handoff tool with rates of medical errors.

August 17, 2016

Post-discharge adverse events among African American and Caucasian patients of an urban community hospital.

July 15, 2020

30-day potentially avoidable readmissions due to adverse drug events.

May 3, 2017

Moving beyond readmission penalties: creating an ideal process to improve transitional care.

January 16, 2013

Hospital-based medication reconciliation practices: a systematic review.

July 11, 2012

Inability of providers to predict unplanned readmissions.

April 6, 2011

Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists.

October 31, 2007

Trends in primary care clinician perceptions of a new electronic health record.

February 11, 2009

Clinical pharmacists and inpatient medical care: a systematic review.

May 17, 2006

The impact of automated notification on follow-up of actionable tests pending at discharge: a cluster-randomized controlled trial.

April 11, 2018

Patient and physician experience with interhospital transfer: a qualitative study.

May 29, 2019

Impact of regionalized care on concordance of plan and preventable adverse events on general medicine services.

March 16, 2016

User-centered collaborative design and development of an inpatient safety dashboard.

September 20, 2017

Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out.

December 5, 2007

Health literacy and medication understanding among hospitalized adults.

December 21, 2011

Economic value of pharmacist-led medication reconciliation for reducing medication errors after hospital discharge.

November 2, 2016

Impact of resident workload and handoff training on patient outcomes.

April 4, 2012

Impact of incorporating pharmacy claims data into electronic medication reconciliation.

March 4, 2015

Effects of an online personal health record on medication accuracy and safety: a cluster-randomized trial.

May 23, 2012

Post-discharge adverse events among urban and rural patients of an urban community hospital: a prospective cohort study.

May 20, 2015

Providers' and patients' perspectives on diagnostic errors in the acute care setting.

February 15, 2023

Effects of a multimodal transitional care intervention in patients at high risk of readmission: the TARGET-READ randomized clinical trial.

May 17, 2023

Implementation, evaluation, and recommendations for extension of AHRQ Common Formats to capture patient- and carepartner-generated safety data.

July 11, 2018

Effects of a multifaceted medication reconciliation quality improvement intervention on patient safety: final results of the MARQUIS study.

September 12, 2018

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

November 16, 2011

Postdischarge adverse events among neonates admitted to the neonatal intensive care unit.

September 7, 2022

Implementation strategies in the context of medication reconciliation: a qualitative study.

July 14, 2021

Development of a tool within the electronic medical record to facilitate medication reconciliation after hospital discharge.

May 4, 2011

Hospital ward adaptation during the COVID-19 pandemic: a national survey of academic medical centers.

September 23, 2020

Evaluation of an inpatient computerized medication reconciliation system.

May 21, 2008

Impact of an automated email notification system for results of tests pending at discharge: a cluster-randomized controlled trial.

November 27, 2013

Association of communication between hospital-based physicians and primary care providers with patient outcomes.

January 21, 2009

Improving medication reconciliation with comprehensive evaluation at a Veterans Affairs skilled-nursing facility.

July 21, 2021

The burden of opioid-related adverse drug events on hospitalized previously opioid-free surgical patients.

March 10, 2021

The Rural VA Multi-Center Medication Reconciliation Quality Improvement Study (R-VA-MARQUIS).

February 12, 2020

Effect of patient- and medication-related factors on inpatient medication reconciliation errors.

March 7, 2012

Lessons learned implementing a complex and innovative patient safety learning laboratory project in a large academic medical center

January 15, 2020

The HOSPITAL score predicts potentially preventable 30-day readmissions in conditions targeted by the Hospital Readmissions Reduction Program.

June 14, 2017

Design and implementation of an automated email notification system for results of tests pending at discharge.

February 29, 2012

Analyzing diagnostic errors in the acute setting: a process-driven approach.

October 20, 2021

Journal Article

Study

Implementation of a medication reconciliation risk stratification tool integrated within an electronic health record: a case series of three academic medical centers.

March 29, 2023

Role of pharmacist counseling in preventing adverse drug events after hospitalization.

March 22, 2006

A framework for engaging physicians in quality and safety.

August 24, 2011

A structured approach to EHR surveillance of diagnostic error in acute care: an exploratory analysis of two institutionally-defined case cohorts.

December 7, 2022

Preventability and causes of readmissions in a national cohort of general medicine patients.

May 4, 2016

Classifying and predicting errors of inpatient medication reconciliation.

July 9, 2008

A systematic review of patient safety measures in adult primary care.

May 18, 2016

Effect of pharmacist counseling intervention on health care utilization following hospital discharge: a randomized control trial.

June 8, 2016

A piece of my mind. Trials and tribulations.

August 23, 2017

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

April 29, 2009

What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study.

April 12, 2023

Prevalence and predictability of low-yield inpatient laboratory diagnostic tests.

September 25, 2019

I-PASS Mentored Implementation Handoff Curriculum: implementation guide and resources.

March 10, 2019

A toolkit to disseminate best practices in inpatient medication reconciliation: Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS).

July 31, 2013

Effects of a refined evidence-based toolkit and mentored implementation on medication reconciliation at 18 hospitals: results of the MARQUIS2 study.

May 19, 2021

Identifying diagnostic errors in primary care using an electronic screening algorithm.

February 21, 2007

I-PASS mentored implementation handoff curriculum: champion training materials.

March 13, 2019

Partnering with VA stakeholders to develop a comprehensive patient safety data display: lessons learned from the field.

February 11, 2015

Potential consequences of patient complications for surgeon well-being: a systematic review.

April 17, 2019

Effect of a pharmacist intervention on clinically important medication errors after hospital discharge: a randomized trial.

July 18, 2012

Prevalence and causes of diagnostic errors in hospitalized patients under investigation for COVID-19.

April 12, 2023

The hospital discharge: a review of a high risk care transition with highlights of a reengineered discharge process.

June 20, 2007

Understanding the barriers to physician error reporting and disclosure: a systemic approach to a systemic problem.

March 12, 2014

Fast does not imply flawed: analyzing emergency physician productivity and medical errors.

December 14, 2022

Comparing NICU teamwork and safety climate across two commonly used survey instruments.

November 30, 2016

Comparing two safety culture surveys: Safety Attitudes Questionnaire and Hospital Survey on Patient Safety.

April 25, 2012

“I made a mistake!”: a narrative analysis of experienced physicians' stories of preventable error.

January 20, 2021

Piece of my mind. Stories doctors tell.

July 19, 2017

Computerized provider order entry and prescribing and the evidence for safe practice: update for the clinical nurse specialist.

July 25, 2007

Governing the safety of artificial intelligence in healthcare.

May 8, 2019

Imitating incidents: how simulation can improve safety investigation and learning from adverse events.

June 27, 2018

Remembering to learn: the overlooked role of remembrance in safety improvement.

December 7, 2016

Investigating for improvement? Five strategies to ensure national patient safety investigations improve patient safety.

June 5, 2019

The problem with incident reporting.

October 28, 2015

Early warnings, weak signals and learning from healthcare disasters.

April 9, 2014

Learning from patient safety incidents: creating participative risk regulation in healthcare.

February 27, 2008

How surgeons disclose medical errors to patients: a study using standardized patients.

December 7, 2005

Using a human factors framework to assess clinician perceptions of and barriers to high reliability in hand hygiene.

June 14, 2023

Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain?

March 17, 2010

Description and yield of current quality and safety review in selected US academic emergency departments.

August 30, 2017

Effect of bar-code technology on the safety of medication administration.

May 12, 2010

Cost-effectiveness of an electronic medication ordering and administration system in reducing adverse drug events.

June 6, 2007

The Quality and Safety Educators Academy: fulfilling an unmet need for faculty development.

May 22, 2013

Medication safety pharmacy technician in a large, tertiary care, community hospital.

March 30, 2016

Use of cellular telephones in the hospital environment.

March 28, 2007

Disclosing errors that affect multiple patients.

June 3, 2009

Results of a medication reconciliation survey from the 2006 Society of Hospital Medicine national meeting.

January 14, 2009

Response of practicing chiropractors during the early phase of the COVID-19 pandemic: a descriptive report.

July 8, 2020

When order sets do not align with clinician workflow: assessing practice patterns in the electronic health record.

June 19, 2019

Electronic health record-based surveillance of diagnostic errors in primary care.

November 2, 2011

Timely follow-up of abnormal diagnostic imaging test results in an outpatient setting: are electronic medical records achieving their potential?

October 7, 2009

Delivering high reliability in maternity care: in situ simulation as a source of organisational resilience.

July 10, 2019

Can we import improvements from industry to healthcare?

May 1, 2019

Contraindicated medication use in dialysis patients undergoing percutaneous coronary intervention.

December 16, 2009

Measures and measurement of high-performance work systems in health care settings: propositions for improvement.

February 9, 2011

Development and sustainability of an inpatient-to-outpatient discharge handoff tool: a quality improvement project.

April 30, 2014

Related Resources

Just what the doctor ordered: missed ordering of venous thromboembolism chemoprophylaxis is associated with increased VTE events in high-risk general surgery patients.

August 30, 2023

Inappropriate prescriptions of direct oral anticoagulants (DOACs) in hospitalized patients: a narrative review.

May 10, 2023

Modes of failure in venous thromboembolism prophylaxis.

September 28, 2022

Patient Safety Innovations

The Johns Hopkins Venous Thromboembolism (VTE) Collaborative Studies and Implements Methods to Prevent Avoidable Cases of Hospital Associated VTE

April 7, 2022

Prescribing errors with low-molecular-weight heparins.

October 13, 2021

WebM&M Cases

Updates in the Management of High-Risk Pulmonary Embolism

May 1, 2019

WebM&M Cases

Hip Fractures in Older Patients: the Case for Geriatrics Comanagement

April 1, 2019

ASH Clinical Practice Guidelines on Venous Thromboembolism.

January 9, 2019

Practices to prevent venous thromboembolism: a brief review.

February 19, 2014

Effectiveness of written hospitalist sign-outs in answering overnight inquiries.

November 20, 2013

What do patients think about year-end resident continuity clinic handoffs?: a qualitative study.

May 22, 2013

Patient Safety.

February 13, 2013

What is the NHS Safety Thermometer?

November 28, 2012

Improvement in the detection of adverse drug events by the use of electronic health and prescription records: an evaluation of two trigger tools.

August 29, 2012

Long-term reduction in adverse drug events: an evidence-based improvement model.

July 18, 2012

Harm Free Care.

May 9, 2012

Use of an appreciative inquiry approach to improve resident sign-out in an era of multiple shift changes.

January 25, 2012

Anticoagulation-associated adverse drug events.

December 14, 2011

Patient Safety Dialogue: evaluation of an intervention aimed at achieving an improved patient safety culture.

October 19, 2011

Why patient summaries in electronic health records do not provide the cognitive support necessary for nurses' handoffs on medical and surgical units: insights from interviews and observations.

October 19, 2011

Wristbands as aids to reduce misidentification: an ethnographically guided task analysis.

September 28, 2011

Incidence of potentially avoidable urgent readmissions and their relation to all-cause urgent readmissions.

September 28, 2011

Physician reporting of clinically significant events through a computerized patient sign-out system.

September 14, 2011

Clinical and safety impact of an inpatient pharmacist-directed anticoagulation service.

August 24, 2011

The care transitions intervention: translating from efficacy to effectiveness.

August 10, 2011

Implementing handoff communication.

June 15, 2011

Racial disparities in the frequency of patient safety events: results from the National Medicare Patient Safety Monitoring System.

June 1, 2011

Veterans Affairs initiative to prevent methicillin-resistant Staphylococcus aureus infections.

April 27, 2011

Driving out errors.

April 27, 2011

How active resisters and organizational constipators affect health care–acquired infection prevention efforts.

April 13, 2011

See More About The Topic

General Hospitals

Health Care Executives and Administrators

General Internal Medicine

Hospital Medicine

Discontinuities, Gaps, and Hand-Off Problems

Deficits in discharge documentation in patients transferred to rehabilitation facilities on anticoagulation: results of a systemwide evaluation.

Implementation of a medication reconciliation risk stratification tool integrated within an electronic health record: a case series of three academic medical centers.

The Johns Hopkins Venous Thromboembolism (VTE) Collaborative Studies and Implements Methods to Prevent Avoidable Cases of Hospital Associated VTE

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Deficits in discharge documentation in patients transferred to rehabilitation facilities on anticoagulation: results of a systemwide evaluation.

Implementation of a medication reconciliation risk stratification tool integrated within an electronic health record: a case series of three academic medical centers.

The Johns Hopkins Venous Thromboembolism (VTE) Collaborative Studies and Implements Methods to Prevent Avoidable Cases of Hospital Associated VTE

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site