AHRQ Patient Safety Network

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Safety Target

•Device-related Complications (108)

•Diagnostic Errors (94)

•Identification Errors (64)

•Discontinuities, Gaps, and Hand-Off Problems (527)

•Fatigue and Sleep Deprivation (82)

•Medication Safety (627)

•Medical Complications (331)

•Nonsurgical Procedural Complications (42)

•Surgical Complications (245)

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•Africa (2)

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Resource Types

•Audiovisual (21)

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Error Types

•Epidemiology of Errors and Adverse Events (610)

•Active Errors (370)

•Latent Errors (191)

•Near Miss (38)

Approach to Improving Safety

•Quality Improvement Strategies (597)

•Legal and Policy Approaches (224)

•Error Reporting and Analysis (669)

•Communication Improvement (666)

•Human Factors Engineering (296)

•Teamwork (192)

•Specialization of Care (191)

•Logistical Approaches (224)

•Culture of Safety (328)

•Technologic Approaches (387)

•Education and Training (451)

Clinical Areas

•Allied Health Services (4)

•Medicine (1971)

•Nursing (202)

•Pharmacy (240)

Target Audience

•Health Care Providers (1524)

•Health Care Executives and Administrators (1945)

•Non-Health Care Professionals (826)

•Patients (169)

Setting of Care
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Hospitals

•General Hospitals (581)

•Children’s Hospitals (44)

•Specialty Hospitals (29)

1 - 20 of 2364

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STUDY

An institution-wide handoff task force to standardise and improve physician handoffs.

Horwitz LI, Schuster KM, Thung SF, et al. BMJ Qual Saf. 2012;21:863-871.

COMMENTARY

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.

DeRienzo CM, Frush K, Barfield ME, et al. Acad Med. 2012;87:403-410.

REVIEW

Review of computerized physician handoff tools for improving the quality of patient care.

Li P, Ali S, Tang C, Ghali WA, Stelfox HT. J Hosp Med. 2012 Nov 20; [Epub ahead of print].

REVIEW

Doctors' handovers in hospitals: a literature review.

Raduma-Tomàs MA, Flin R, Yule S, Williams D. BMJ Qual Saf. 2011;20:128-133.

STUDY

Implementing peer evaluation of handoffs: associations with experience and workload.

Arora VM, Greenstein EA, Woodruff JN, Staisiunas PG, Farnan JM. J Hosp Med. 2013;8:132-136.

REVIEW

Impact of reduction in working hours for doctors in training on postgraduate medical education and patients' outcomes: systematic review.

Moonesinghe SR, Lowery J, Shahi N, Millen A, Beard JD. BMJ. 2011;342:d1580.

STUDY

Effect of a systems intervention on the quality and safety of patient handoffs in an internal medicine residency program.

Graham KL, Marcantonio ER, Huang GC, Yang J, Davis RB, Smith CC. J Gen Intern Med. 2013 Apr 18; [Epub ahead of print].

MULTI-USE WEBSITE

Handover: Improving the Continuity of Patient Care Through Identification and Implementation of Novel Handover Processes in Europe.

University Medical Centre Utrecht.

STUDY

Who's covering our loved ones: surprising barriers in the sign-out process.

Antonoff MB, Berdan EA, Kirchner VA, et al. Am J Surg. 2013;205:77-84.

STUDY

Evaluation of a predevelopment service delivery intervention: an application to improve clinical handovers.

Yao GL, Novielli N, Manaseki-Holland S, et al; European HANDOVER Research Collaborative. BMJ Qual Saf. 2012;21(suppl 1):i29-i38.

COMMENTARY

Time to sign off on signout.

Stein DM, Stetson PD. Acad Med. 2011;86:804-806.

REVIEW

The effects of patient handoff characteristics on subsequent care: a systematic review and areas for future research.

Foster S, Manser T. Acad Med. 2012;87:1105-1124.

STUDY

The computerized rounding report: implementation of a model system to support transitions of care.

Wohlauer MV, Rove KO, Pshak TJ, et al. J Surg Res. 2012;172:11-17.

COMMENTARY

Why patients need leaders: introducing a ward safety checklist.

Amin Y, Grewcock D, Andrews S, Halligan A. J R Soc Med. 2012;105:377-383.

STUDY

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

Helms AS, Perez TE, Baltz J, et al. J Gen Intern Med. 2012;27:287-291.

COMMENTARY

Transition of care for hospitalized elderly patients—development of a discharge checklist for hospitalists.

Halasyamani L, Kripalani S, Coleman E, et al. J Hosp Med. 2006;1:354-360.

REVIEW

Prescribing errors in hospital practice.

Tully MP. Br J Clin Pharmacol. 2012;74:668-675.

TOOLS/TOOLKIT

Improving Transitions of Care: Hand-off Communications.

Oakbrook Terrace, IL: Joint Commission Center for Transforming Healthcare; June 2012.

COMMENTARY

Implementation of a specialized pharmacy team to monitor high-risk medications during discharge.

Martin ES III, Overstreet RL, Jackson-Khalil LR, McCollough HL, Meyer TA, Xu Q. Am J Health Syst Pharm. 2013;70:18-21.

STUDY

Measuring handoff quality in labor and delivery: development, validation, and application of the Coordination of Handoff Effectiveness Questionnaire (CHEQ).

Block M, Ehrenworth JF, Cuce VM, et al. Jt Comm J Qual Patient Saf. 2013;39:213-220.

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