Study The hospital discharge: a review of a high risk care transition with highlights of a reengineered discharge process. Citation Text: Greenwald JL, Denham CR, Jack BW. The Hospital Discharge. J Patient Saf. 2008;3(2). doi:10.1097/01.jps.0000236916.94696.12. Copy Citation Format: DOIGoogle ScholarBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL June 20, 2007 Greenwald JL, Denham CR, Jack BW. J Patient Saf. 2008;3(2). View more articles from the same authors. In this AHRQ-funded study, the authors reviewed elements of the hospital discharge process and defined 11 components that should be required to ensure a reliable and safe hospital discharge. Available at Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Cite Citation Citation Text: Greenwald JL, Denham CR, Jack BW. The Hospital Discharge. J Patient Saf. 2008;3(2). doi:10.1097/01.jps.0000236916.94696.12. Copy Citation Format: DOIGoogle ScholarBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Related Resources From the Same Author(s) A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. February 11, 2009 Results of a medication reconciliation survey from the 2006 Society of Hospital Medicine national meeting. January 14, 2009 A safe practice standard for barcode technology. June 3, 2015 Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. September 18, 2013 Safe use of electronic health records and health information technology systems: trust but verify. December 18, 2013 The National Quality Forum safe practice standard for computerized physician order entry: updating a critical patient safety practice. January 10, 2007 Effect of reducing interns' weekly work hours on sleep and attentional failures. March 27, 2005 Making inpatient medication reconciliation patient centered, clinically relevant and implementable: a consensus statement on key principles and necessary first steps. October 27, 2010 Project BOOST: effectiveness of a multihospital effort to reduce rehospitalization. August 21, 2013 A toolkit to disseminate best practices in inpatient medication reconciliation: Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS). July 31, 2013 Project BOOST implementation: lessons learned. September 10, 2014 The Research on Adverse Drug Events and Reports (RADAR) project. May 18, 2005 Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016 March 3, 2017 The cost of harm and savings through safety: using simulated patients for leadership decision support. September 12, 2012 Impact of computerized prescriber order entry on the incidence of adverse drug events in pediatric inpatients. November 21, 2007 Quality initiatives: developing a radiology quality and safety program: a primer. August 26, 2009 The partnership with patients: a call to action for leaders. September 7, 2011 Radiation protection and dose monitoring in medical imaging: a journey from awareness, through accountability, ability and action … but where will we arrive? December 4, 2013 Are you listening...Are you really listening? September 17, 2008 Disclosure through our eyes. March 19, 2008 SBAR for patients. March 12, 2008 No excuses: the reality that demands action. September 1, 2005 TRUST: the 5 rights of the second victim. June 27, 2007 The new patient safety officer: a lifeline for patients, a life jacket for CEOs. April 4, 2007 Applying trigger tools to detect adverse events associated with outpatient surgery. March 16, 2011 Assessing the potential adoption and usefulness of concurrent, action-oriented, electronic adverse drug event triggers designed for the outpatient setting. June 24, 2015 Recommendations to improve the usability of drug–drug interaction clinical decision support alerts. November 25, 2015 A multidisciplinary teamwork training program: The Triad for Optimal Patient Safety (TOPS) experience. October 15, 2008 Incidence and preventability of adverse drug events among older persons in the ambulatory setting. March 6, 2005 The Critical Care Safety Study: the incidence and nature of adverse events and serious medical errors in intensive care. August 24, 2005 Effect of reducing interns' work hours on serious medical errors in intensive care units. March 27, 2005 Nurse working conditions and patient safety outcomes. June 6, 2007 Recovery from medical errors: the critical care nursing safety net. January 31, 2006 Impact of extended-duration shifts on medical errors, adverse events, and attentional failures. December 13, 2006 Extended work duration and the risk of self-reported percutaneous injuries in interns. September 6, 2006 Alternatives to potentially inappropriate medications for use in e-prescribing software: triggers and treatment algorithms. July 20, 2011 Effective implementation of work-hour limits and systemic improvements. November 28, 2007 Unintended effects of a computerized physician order entry nearly hard-stop alert to prevent a drug interaction: a randomized controlled trial. October 13, 2010 Patient reported receipt of medication instructions for warfarin is associated with reduced risk of serious bleeding events. October 1, 2008 Identifying and quantifying medication errors: evaluation of rapidly discontinued medication orders submitted to a computerized physician order entry system. May 21, 2008 Nurse staffing and inpatient hospital mortality. March 23, 2011 Delayed rapid response team activation is associated with increased hospital mortality, morbidity, and length of stay in a tertiary care institution. October 28, 2015 Implementation of a preoperative briefing protocol improves accuracy of teamwork assessment in the operating room. October 8, 2008 Practice advisory for the prevention and management of operating room fires. May 7, 2008 Developing indicators of inpatient adverse drug events through nonlinear analysis using administrative data. October 24, 2007 Lacerations and embedded needles caused by epinephrine autoinjector use in children. October 28, 2015 ACR guidance document on MR safe practices: 2013. March 21, 2013 Low literacy impairs comprehension of prescription drug warning labels. July 26, 2006 Relationship between preventability of death after coronary artery bypass graft surgery and all-cause risk-adjusted mortality rates. July 9, 2008 Medication errors with the use of allopurinol and colchicine: a retrospective study of a national, anonymous Internet-accessible error reporting system. March 8, 2006 Design and implementation of an automated email notification system for results of tests pending at discharge. February 29, 2012 Effect of a pharmacist intervention on clinically important medication errors after hospital discharge: a randomized trial. July 18, 2012 Role of pharmacist counseling in preventing adverse drug events after hospitalization. March 22, 2006 Effects of the introduction of the WHO "Surgical Safety Checklist" on in-hospital mortality: a cohort study. January 30, 2005 Consensus statement on effective communication of urgent diagnoses and significant, unexpected diagnoses in surgical pathology and cytopathology from the College of American Pathologists and Association of Directors of Anatomic and Surgical Pathology. October 26, 2011 Increased appropriateness of customized alert acknowledgement reasons for overridden medication alerts in a computerized provider order entry system. January 6, 2016 Development of a tool within the electronic medical record to facilitate medication reconciliation after hospital discharge. May 4, 2011 Impact of an automated email notification system for results of tests pending at discharge: a cluster-randomized controlled trial. November 27, 2013 Impact of incorporating pharmacy claims data into electronic medication reconciliation. March 4, 2015 Simulation-based trial of surgical-crisis checklists. January 30, 2013 Leadership, safety climate, and continuous quality improvement: impact on process quality and patient safety. April 16, 2014 High rates of adverse drug events in a highly computerized hospital. May 25, 2005 Exploring strategies for reducing hospital errors. April 19, 2006 Organizational culture, critical success factors, and the reduction of hospital errors. April 18, 2007 Implementation of patient safety initiatives in US hospitals. May 24, 2006 Changes in medical errors after implementation of a handoff program. November 12, 2014 Medication errors in acute cardiovascular and stroke patients. A scientific statement from the American Heart Association. April 7, 2010 Ethical considerations and patient safety concerns for cancelling non-urgent surgeries during the COVID-19 pandemic: a review. May 12, 2021 Reducing catheter-associated bloodstream infections in the pediatric intensive care unit: business case for quality improvement. October 13, 2010 Errors associated with outpatient computerized prescribing systems. July 13, 2011 Time of day and the decision to prescribe antibiotics. October 22, 2014 John M. Eisenberg Patient Safety Awards. System innovation: Veterans Health Administration National Center for Patient Safety. March 6, 2005 Strategies for detecting adverse drug events among older persons in the ambulatory setting. March 6, 2005 American College of Endocrinology and American Association of Clinical Endocrinologists position statement on patient safety and medical system errors in diabetes and endocrinology. December 7, 2005 Costs of adverse events in intensive care units. September 26, 2007 Classifying and predicting errors of inpatient medication reconciliation. July 9, 2008 Post-discharge adverse events among urban and rural patients of an urban community hospital: a prospective cohort study. May 20, 2015 Effects of an online personal health record on medication accuracy and safety: a cluster-randomized trial. May 23, 2012 Adherence to black box warnings for prescription medications in outpatients. February 22, 2006 Medication safety in a psychiatric hospital. March 21, 2007 Handoffs in the era of duty hours reform: a focused review and strategy to address changes in the Accreditation Council for Graduate Medical Education Common Program Requirements. March 14, 2012 Crisis management during anaesthesia: the development of an anaesthetic crisis management manual. June 22, 2005 Postoperative sepsis in the United States. January 19, 2011 Using in situ simulation to identify and resolve latent environmental threats to patient safety: case study involving a labor and delivery ward. September 9, 2009 A paradigm shift to balance safety and quality in pediatric pain management. March 6, 2013 Medication safety in community pharmacy: a qualitative study of the sociotechnical context. December 2, 2009 Improving transfusion safety: implementation of a comprehensive computerized bar code-based tracking system for detecting and preventing errors. April 9, 2008 Effectiveness of patient safety training in equipping medical students to recognise safety hazards and propose robust interventions. March 10, 2010 NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit. January 20, 2010 Prevalence of adverse events in the hospitals of five Latin American countries: results of the 'Iberoamerican Study of Adverse Events' (IBEAS). August 10, 2011 Computerised physician order entry-related medication errors: analysis of reported errors and vulnerability testing of current systems. January 28, 2015 Adverse respiratory events in anesthesia: a closed claims analysis. March 6, 2005 Building safer systems by ecological design: using restoration science to develop a medication safety intervention. April 12, 2006 The natural history of recovery for the healthcare provider "second victim" after adverse patient events. October 21, 2009 Developing and implementing new safe practices: voluntary adoption through statewide collaboratives. August 16, 2006 Educational quality improvement report: outcomes from a revised morbidity and mortality format that emphasised patient safety. December 19, 2007 Findings of the first consensus conference on medical emergency teams. August 16, 2006 Interns' compliance with Accreditation Council for Graduate Medical Education work-hour limits. September 6, 2006 Excess dosing of antiplatelet and antithrombin agents in the treatment of non–ST-segment elevation acute coronary syndromes. January 11, 2006 Communication practices on 4 Harvard surgical services: a surgical safety collaborative. November 11, 2009 View More Related Resources Estimating the impact on patient safety of enabling the digital transfer of patients' prescription information in the English NHS. April 17, 2024 Patient Safety Primers Inpatient Transitions of Care: Challenges and Safety Practices March 27, 2024 Patient Safety Innovations Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer July 31, 2023 Patient Safety Innovations Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis May 31, 2023 Patient Safety Innovations Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans May 31, 2023 Annual Perspective Improving Diagnostic Safety and Quality April 26, 2023 What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study. April 12, 2023 Evaluating patient identification practices during intrahospital transfers: a human factors approach. March 29, 2023 Patient Safety Innovations Enhancing Support for Patients’ Social Needs to Reduce Hospital Readmissions and Improve Health Outcomes March 29, 2023 Challenges and strategies for patient safety in primary care: a qualitative study. September 28, 2022 Differences in medication reconciliation interventions between six hospitals: a mixed method study. June 29, 2022 Sources of medication omissions among hospitalized older adults with polypharmacy. March 9, 2022 A mixed methods evaluation of medication reconciliation in the primary care setting. March 2, 2022 Effect of medication reconciliation at hospital admission on 30-day returns to hospital: a randomized clinical trial. October 6, 2021 Patient Safety Innovations ECHO-Care Transitions Successfully Reduces Patient Readmissions from Skilled Nursing Facilities, Reduces Length of Stay August 25, 2021 Implementation strategies in the context of medication reconciliation: a qualitative study. July 14, 2021 Obtaining the best possible medication history at hospital admission: description of a pharmacy technician-driven program to identify medication discrepancies. June 23, 2021 Effects of pharmacist-conducted medication reconciliation at discharge on 30-day readmission rates of patients with chronic obstructive pulmonary disease. June 9, 2021 Effects of a refined evidence-based toolkit and mentored implementation on medication reconciliation at 18 hospitals: results of the MARQUIS2 study. May 19, 2021 Patient harm resulting from medication reconciliation process failures: a study of serious events reported by Pennsylvania hospitals. March 24, 2021 Using medication containers during pharmacist transitional care visits and impact on medication discrepancies identified and hospital readmission risk. November 11, 2020 Complications associated with the anesthesia transport of pediatric patients: an analysis of the Wake Up Safe database. October 14, 2020 Longitudinal medication reconciliation at hospital admission, discharge and post-discharge. August 26, 2020 Pharmacist-led program to improve transitions from acute care to skilled nursing facility care. July 8, 2020 Medication order errors at hospital admission among children with medical complexity July 8, 2020 Applying the Medications at Transitions and Clinical Handoffs Toolkit in a rural primary care clinic: implications for nursing, patients, and caregivers. July 8, 2020 WebM&M Cases When the Indications for Drug Administration Blur June 24, 2020 Work system barriers and facilitators in inpatient care transitions of pediatric trauma patients. March 11, 2020 Prevalence of potentially inappropriate prescribing in older people in primary care and its association with hospital admission: longitudinal study. December 5, 2018 Evaluating the implementation of Project Re-Engineered Discharge (RED) in five Veterans Health Administration (VHA) hospitals. October 17, 2018 View More See More About The Topic Hospitals Facility and Group Administrators Quality and Safety Professionals Structured Hand-offs Medication Reconciliation
A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. February 11, 2009
Results of a medication reconciliation survey from the 2006 Society of Hospital Medicine national meeting. January 14, 2009
Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. September 18, 2013
Safe use of electronic health records and health information technology systems: trust but verify. December 18, 2013
The National Quality Forum safe practice standard for computerized physician order entry: updating a critical patient safety practice. January 10, 2007
Making inpatient medication reconciliation patient centered, clinically relevant and implementable: a consensus statement on key principles and necessary first steps. October 27, 2010
A toolkit to disseminate best practices in inpatient medication reconciliation: Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS). July 31, 2013
Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016 March 3, 2017
The cost of harm and savings through safety: using simulated patients for leadership decision support. September 12, 2012
Impact of computerized prescriber order entry on the incidence of adverse drug events in pediatric inpatients. November 21, 2007
Radiation protection and dose monitoring in medical imaging: a journey from awareness, through accountability, ability and action … but where will we arrive? December 4, 2013
Assessing the potential adoption and usefulness of concurrent, action-oriented, electronic adverse drug event triggers designed for the outpatient setting. June 24, 2015
Recommendations to improve the usability of drug–drug interaction clinical decision support alerts. November 25, 2015
A multidisciplinary teamwork training program: The Triad for Optimal Patient Safety (TOPS) experience. October 15, 2008
Incidence and preventability of adverse drug events among older persons in the ambulatory setting. March 6, 2005
The Critical Care Safety Study: the incidence and nature of adverse events and serious medical errors in intensive care. August 24, 2005
Effect of reducing interns' work hours on serious medical errors in intensive care units. March 27, 2005
Impact of extended-duration shifts on medical errors, adverse events, and attentional failures. December 13, 2006
Extended work duration and the risk of self-reported percutaneous injuries in interns. September 6, 2006
Alternatives to potentially inappropriate medications for use in e-prescribing software: triggers and treatment algorithms. July 20, 2011
Unintended effects of a computerized physician order entry nearly hard-stop alert to prevent a drug interaction: a randomized controlled trial. October 13, 2010
Patient reported receipt of medication instructions for warfarin is associated with reduced risk of serious bleeding events. October 1, 2008
Identifying and quantifying medication errors: evaluation of rapidly discontinued medication orders submitted to a computerized physician order entry system. May 21, 2008
Delayed rapid response team activation is associated with increased hospital mortality, morbidity, and length of stay in a tertiary care institution. October 28, 2015
Implementation of a preoperative briefing protocol improves accuracy of teamwork assessment in the operating room. October 8, 2008
Developing indicators of inpatient adverse drug events through nonlinear analysis using administrative data. October 24, 2007
Lacerations and embedded needles caused by epinephrine autoinjector use in children. October 28, 2015
Relationship between preventability of death after coronary artery bypass graft surgery and all-cause risk-adjusted mortality rates. July 9, 2008
Medication errors with the use of allopurinol and colchicine: a retrospective study of a national, anonymous Internet-accessible error reporting system. March 8, 2006
Design and implementation of an automated email notification system for results of tests pending at discharge. February 29, 2012
Effect of a pharmacist intervention on clinically important medication errors after hospital discharge: a randomized trial. July 18, 2012
Role of pharmacist counseling in preventing adverse drug events after hospitalization. March 22, 2006
Effects of the introduction of the WHO "Surgical Safety Checklist" on in-hospital mortality: a cohort study. January 30, 2005
Consensus statement on effective communication of urgent diagnoses and significant, unexpected diagnoses in surgical pathology and cytopathology from the College of American Pathologists and Association of Directors of Anatomic and Surgical Pathology. October 26, 2011
Increased appropriateness of customized alert acknowledgement reasons for overridden medication alerts in a computerized provider order entry system. January 6, 2016
Development of a tool within the electronic medical record to facilitate medication reconciliation after hospital discharge. May 4, 2011
Impact of an automated email notification system for results of tests pending at discharge: a cluster-randomized controlled trial. November 27, 2013
Impact of incorporating pharmacy claims data into electronic medication reconciliation. March 4, 2015
Leadership, safety climate, and continuous quality improvement: impact on process quality and patient safety. April 16, 2014
Organizational culture, critical success factors, and the reduction of hospital errors. April 18, 2007
Medication errors in acute cardiovascular and stroke patients. A scientific statement from the American Heart Association. April 7, 2010
Ethical considerations and patient safety concerns for cancelling non-urgent surgeries during the COVID-19 pandemic: a review. May 12, 2021
Reducing catheter-associated bloodstream infections in the pediatric intensive care unit: business case for quality improvement. October 13, 2010
John M. Eisenberg Patient Safety Awards. System innovation: Veterans Health Administration National Center for Patient Safety. March 6, 2005
Strategies for detecting adverse drug events among older persons in the ambulatory setting. March 6, 2005
American College of Endocrinology and American Association of Clinical Endocrinologists position statement on patient safety and medical system errors in diabetes and endocrinology. December 7, 2005
Post-discharge adverse events among urban and rural patients of an urban community hospital: a prospective cohort study. May 20, 2015
Effects of an online personal health record on medication accuracy and safety: a cluster-randomized trial. May 23, 2012
Handoffs in the era of duty hours reform: a focused review and strategy to address changes in the Accreditation Council for Graduate Medical Education Common Program Requirements. March 14, 2012
Crisis management during anaesthesia: the development of an anaesthetic crisis management manual. June 22, 2005
Using in situ simulation to identify and resolve latent environmental threats to patient safety: case study involving a labor and delivery ward. September 9, 2009
Medication safety in community pharmacy: a qualitative study of the sociotechnical context. December 2, 2009
Improving transfusion safety: implementation of a comprehensive computerized bar code-based tracking system for detecting and preventing errors. April 9, 2008
Effectiveness of patient safety training in equipping medical students to recognise safety hazards and propose robust interventions. March 10, 2010
NICU medication errors: identifying a risk profile for medication errors in the neonatal intensive care unit. January 20, 2010
Prevalence of adverse events in the hospitals of five Latin American countries: results of the 'Iberoamerican Study of Adverse Events' (IBEAS). August 10, 2011
Computerised physician order entry-related medication errors: analysis of reported errors and vulnerability testing of current systems. January 28, 2015
Building safer systems by ecological design: using restoration science to develop a medication safety intervention. April 12, 2006
The natural history of recovery for the healthcare provider "second victim" after adverse patient events. October 21, 2009
Developing and implementing new safe practices: voluntary adoption through statewide collaboratives. August 16, 2006
Educational quality improvement report: outcomes from a revised morbidity and mortality format that emphasised patient safety. December 19, 2007
Interns' compliance with Accreditation Council for Graduate Medical Education work-hour limits. September 6, 2006
Excess dosing of antiplatelet and antithrombin agents in the treatment of non–ST-segment elevation acute coronary syndromes. January 11, 2006
Communication practices on 4 Harvard surgical services: a surgical safety collaborative. November 11, 2009
Estimating the impact on patient safety of enabling the digital transfer of patients' prescription information in the English NHS. April 17, 2024
Patient Safety Innovations Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer July 31, 2023
Patient Safety Innovations Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis May 31, 2023
Patient Safety Innovations Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans May 31, 2023
What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study. April 12, 2023
Evaluating patient identification practices during intrahospital transfers: a human factors approach. March 29, 2023
Patient Safety Innovations Enhancing Support for Patients’ Social Needs to Reduce Hospital Readmissions and Improve Health Outcomes March 29, 2023
Challenges and strategies for patient safety in primary care: a qualitative study. September 28, 2022
Differences in medication reconciliation interventions between six hospitals: a mixed method study. June 29, 2022
Effect of medication reconciliation at hospital admission on 30-day returns to hospital: a randomized clinical trial. October 6, 2021
Patient Safety Innovations ECHO-Care Transitions Successfully Reduces Patient Readmissions from Skilled Nursing Facilities, Reduces Length of Stay August 25, 2021
Implementation strategies in the context of medication reconciliation: a qualitative study. July 14, 2021
Obtaining the best possible medication history at hospital admission: description of a pharmacy technician-driven program to identify medication discrepancies. June 23, 2021
Effects of pharmacist-conducted medication reconciliation at discharge on 30-day readmission rates of patients with chronic obstructive pulmonary disease. June 9, 2021
Effects of a refined evidence-based toolkit and mentored implementation on medication reconciliation at 18 hospitals: results of the MARQUIS2 study. May 19, 2021
Patient harm resulting from medication reconciliation process failures: a study of serious events reported by Pennsylvania hospitals. March 24, 2021
Using medication containers during pharmacist transitional care visits and impact on medication discrepancies identified and hospital readmission risk. November 11, 2020
Complications associated with the anesthesia transport of pediatric patients: an analysis of the Wake Up Safe database. October 14, 2020
Longitudinal medication reconciliation at hospital admission, discharge and post-discharge. August 26, 2020
Pharmacist-led program to improve transitions from acute care to skilled nursing facility care. July 8, 2020
Applying the Medications at Transitions and Clinical Handoffs Toolkit in a rural primary care clinic: implications for nursing, patients, and caregivers. July 8, 2020
Work system barriers and facilitators in inpatient care transitions of pediatric trauma patients. March 11, 2020
Prevalence of potentially inappropriate prescribing in older people in primary care and its association with hospital admission: longitudinal study. December 5, 2018
Evaluating the implementation of Project Re-Engineered Discharge (RED) in five Veterans Health Administration (VHA) hospitals. October 17, 2018