AHRQ Patient Safety Network

The Collection > Quality and Safety Professionals

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Safety Target

•Device-related Complications (93)

•Diagnostic Errors (97)

•Identification Errors (77)

•Discontinuities, Gaps, and Hand-Off Problems (298)

•Fatigue and Sleep Deprivation (50)

•Medication Safety (617)

•Medical Complications (251)

•Nonsurgical Procedural Complications (62)

•Surgical Complications (247)

•Transfusion Complications (9)

•Psychological and Social Complications (63)

Origin/Sponsor

•Asia (22)

•Australia and New Zealand (57)

•Central and South America (1)

•Europe (214)

•North America (1729)

Resource Types

•Audiovisual (8)

•Award (5)

•Book/Report (67)

•Clinical Guideline (3)

•Journal Article (1723)

•Legislation/Regulation (25)

•Meeting/Conference (11)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (127)

•Press Release/Announcement (6)

•Special or Theme Issue (19)

•Tools/Toolkit (19)

•Web Resource (30)

•Grant (2)

Error Types

•Epidemiology of Errors and Adverse Events (565)

•Active Errors (353)

•Latent Errors (127)

•Near Miss (43)

Approach to Improving Safety

•Quality Improvement Strategies (528)

•Legal and Policy Approaches (98)

•Error Reporting and Analysis (606)

•Communication Improvement (496)

•Human Factors Engineering (304)

•Teamwork (195)

•Specialization of Care (152)

•Logistical Approaches (167)

•Culture of Safety (265)

•Technologic Approaches (368)

•Education and Training (394)

Clinical Areas

•Allied Health Services (6)

Target Audience
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Quality and Safety Professionals

Setting of Care

•Hospitals (1412)

•Psychiatric Facilities (5)

•Residential Facilities (33)

•Ambulatory Care (164)

•Outpatient Surgery (17)

•Patient Transport (16)

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COMMENTARY

Ticket to ride: reducing handoff risk during hospital patient transport.

Pesanka DA, Greenhouse PK, Rack LL, et al. J Nurs Care Qual. 2009;24:109-115.

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

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.

REVIEW

Research on nursing handoffs for medical and surgical settings: an integrative review.

Staggers N, Blaz JW. J Adv Nurs. 2013;69:247-262.

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.

COMMENTARY

Utilizing information technology to mitigate the handoff risks caused by resident work hour restrictions.

Bernstein J, MacCourt DC, Jacob DM, Mehta S. Clin Orthop Relat Res. 2010;468:2627-2732.

STUDY

Evaluation of a physician informatics tool to improve patient handoffs.

Flanagan ME, Patterson ES, Frankel RM, Doebbeling BN. J Am Med Inform Assoc. 2009;16:509-515.

REVIEW

Hospitalist handoffs: a systematic review and task force recommendations.

Arora VM, Manjarrez E, Dressler DD, Basaviah P, Halasyamani L, Kripalani S. J Hosp Med. 2009;4:433-440.

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.

STUDY

Impact of resident workload and handoff training on patient outcomes.

Mueller SK, Call SA, McDonald FS, Halvorsen AJ, Schnipper JL, Hicks LS. Am J Med. 2012;125:104-110.

COMMENTARY

2009 National Patient Safety Goals.

Saufl NM. J Perianesth Nurs. 2009;24:114-118.

COMMENTARY

Time to sign off on signout.

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

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.

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.

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.

COMMENTARY

Implementing handoff communication.

Ardoin KB, Broussard L. J Nurses Staff Dev. 2011;27:128-135.

STUDY

Hospital discharge documentation and risk of rehospitalisation.

Hansen LO, Strater A, Smith L, et al. BMJ Qual Saf. 2011;20:773-778.

STUDY

Design and implementation of an application and associated services to support interdisciplinary medication reconciliation efforts at an integrated healthcare delivery network.

Poon EG, Blumenfeld B, Hamann C, et al. J Am Med Inform Assoc. 2006;13:581-592.

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