Background: Adverse events (AEs) occur in 19-28% of patients after discharge and can lead to unanticipated events, including emergency room visits and readmissions.(1,2) While early indicators include new and worsening symptoms (NWS), monitoring of patient-reported NWS is lacking. The 21st Century Cures Act mandates adoption of application programming interfaces (APIs), offering the potential to engage [...]

Background: The ACGME identifies care transitions as both a core competency and focus area for the Clinical Learning Environment Review, but there is a scarcity of literature on standardized curricula designed to teach residents how to facilitate safe discharges. While focusing on the patient as the central locus of the transition is important, an under [...]

Background: Inter-hospital transfer (IHT), defined as the transfer of patients between acute care facilities, is a common practice. Despite assumptions that IHT is done to provide patients with necessary specialized care, the factors which drive patient transfer are highly variable in ways that are not fully explained by differences in patients or hospitals. As such, [...]

Case Presentation: A 22 year-old G1P1000 pregnant woman at 24 weeks presented with hypertensive urgency and newly diagnosed intrauterine growth restriction in the setting of pre-eclampsia. On admission her physical exam and laboratory data were unremarkable. The patient was admitted to maternal fetal medicine for closer fetal monitoring. On hospital day (HD) 9 she began [...]

Background: Pharmacist-led peri-discharge interventions reduce adverse drug events. However, evidence is lacking as to whether there is a business case to fund these non-billable interventions. To test whether such interventions could drive reductions in post-discharge health care utilization to help build a business case, we conducted a pragmatic randomized controlled trial (RCT). Methods: The PHARMacist [...]

Background: The health care transition (HCT) from adolescence to young adulthood is a vulnerable time for youth with special health care needs (YSHCN). Inadequate preparation and support from clinicians, increased responsibilities, and lack of ongoing parental assistance may lead to worsening health conditions. It is generally understood that YSHCN should undergo a structured pediatric to [...]

Background: Electronic medical record (EMR) chart notes are primary tool through which providers communicate their thought processes, clinical decision making and care plans. Our health system consists of 11 hospitals ranging from large academic medical center to small hospitals in Minnesota and Western Wisconsin. Hospital Medicine team represent over 250 providers across all the sites. [...]