AHRQ Patient Safety Network

The Collection > Quality and Safety Professionals

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Safety Target

•Device-related Complications (99)

•Diagnostic Errors (116)

•Identification Errors (79)

•Discontinuities, Gaps, and Hand-Off Problems (304)

•Fatigue and Sleep Deprivation (59)

•Medication Safety (673)

•Medical Complications (257)

•Nonsurgical Procedural Complications (62)

•Surgical Complications (280)

•Transfusion Complications (9)

•Psychological and Social Complications (67)

Origin/Sponsor

•Asia (26)

•Australia and New Zealand (74)

•Central and South America (1)

•Europe (281)

•North America (1784)

Resource Types

•Audiovisual (10)

•Award (5)

•Book/Report (71)

•Clinical Guideline (3)

•Journal Article (1866)

•Legislation/Regulation (26)

•Meeting/Conference (12)

•Newsletter/Journal (3)

•Newspaper/Magazine Article (133)

•Press Release/Announcement (6)

•Special or Theme Issue (22)

•Tools/Toolkit (20)

•Web Resource (29)

•Grant (3)

Error Types

•Epidemiology of Errors and Adverse Events (606)

•Active Errors (395)

•Latent Errors (132)

•Near Miss (46)

Approach to Improving Safety

•Quality Improvement Strategies (551)

•Legal and Policy Approaches (109)

•Error Reporting and Analysis (646)

•Communication Improvement (517)

•Human Factors Engineering (328)

•Teamwork (203)

•Specialization of Care (154)

•Logistical Approaches (174)

•Culture of Safety (266)

•Technologic Approaches (455)

•Education and Training (420)

Clinical Areas

•Allied Health Services (7)

Target Audience
< All

Quality and Safety Professionals

Setting of Care

•Hospitals (1492)

•Psychiatric Facilities (5)

•Residential Facilities (32)

•Ambulatory Care (171)

•Outpatient Surgery (18)

•Patient Transport (16)

1 - 20 of 2209

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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.

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

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.

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

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.

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.

STUDY

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.

Staggers N, Clark L, Blaz JW, Kapsandoy S. Health Informatics J. 2011;17:209-223.

STUDY

Safety of using a computerized rounding and sign-out system to reduce resident duty hours.

Van Eaton EG, McDonough K, Lober WB, Johnson EA, Pellegrini CA, Horvath KD. Acad Med. 2010;85:1189-1195.

COMMENTARY

2009 National Patient Safety Goals.

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

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.

STUDY

The effect of hospital electronic health record adoption on nurse-assessed quality of care and patient safety.

Kutney-Lee A, Kelly D. J Nurs Adm. 2011;41:466-472.

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.

STUDY

The Veterans Affairs shift change physician-to-physician handoff project.

Anderson J, Shroff D, Curtis A, et al. Jt Comm J Qual Patient Saf. 2010;36:62-71.

TOOLS/TOOLKIT

Improving Transitions of Care: Hand-off Communications.

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

STUDY

The importance of preparation for doctors' handovers in an acute medical assessment unit: a hierarchical task analysis.

Raduma-Tomàs MA, Flin R, Yule S, Close S. BMJ Qual Saf. 2012;21:211-217.

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.

NEWSPAPER/MAGAZINE ARTICLE

As industry automates, adverse events continue to haunt caregivers.

Wetzel TG. Health Data Manage. 2011 Feb;19:86, 88, 90 passim.

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.

REVIEW

The published literature on handoffs in hospitals: deficiencies identified in an extensive review.

Cohen MD, Hilligoss PB. Qual Saf Health Care. 2010;19:493-497.

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