AHRQ Patient Safety Network

The Collection > Discontinuities, Gaps, and Hand-Off Problems

PATIENT SAFETY PRIMERS
Adverse Events after Hospital Discharge
Handoffs and Signouts

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Discontinuities, Gaps, and Hand-Off Problems

•Missed or Critical Lab Results (32)

Origin/Sponsor

•Asia (3)

•Australia and New Zealand (27)

Resource Types

•Journal Article (555)

•Legislation/Regulation (11)

•Meeting/Conference (2)

•Newspaper/Magazine Article (78)

•Special or Theme Issue (11)

•Tools/Toolkit (10)

•Web Resource (16)

Error Types

•Epidemiology of Errors and Adverse Events (164)

•Active Errors (118)

•Latent Errors (76)

•Near Miss (7)

Approach to Improving Safety

•Quality Improvement Strategies (137)

•Legal and Policy Approaches (41)

•Error Reporting and Analysis (107)

•Communication Improvement (473)

•Human Factors Engineering (62)

•Teamwork (54)

•Specialization of Care (59)

•Logistical Approaches (111)

•Culture of Safety (34)

•Technologic Approaches (122)

•Education and Training (157)

Clinical Areas

•Allied Health Services (3)

•Medicine (553)

•Nursing (61)

•Pharmacy (70)

Target Audience

•Health Care Providers (516)

•Health Care Executives and Administrators (534)

•Non-Health Care Professionals (202)

•Patients (54)

Setting of Care

•Hospitals (543)

•Psychiatric Facilities (3)

•Residential Facilities (17)

•Ambulatory Care (101)

•Outpatient Surgery (5)

•Patient Transport (14)

1 - 20 of 713

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COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2009;44:730-733.

STUDY

Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study.

Walker PC, Bernstein SJ, Tucker Jones JN, et al. Arch Intern Med. 2009;169:2003-2010.

STUDY

Adverse drug events in hospitalized cardiac patients.

Fanikos J, Cina JL, Baroletti S, Fiumara K, Matta L, Goldhaber SZ. Am J Cardiol. 2007;100:1465-1469.

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

Assessment of a safety enhancement to the hospital medication reconciliation process for elderly patients.

Gizzi LA, Slain D, Hare JT, Sager R, Briggs F 3rd, Palmer CH. Am J Geriatr Pharmacother. 2010;8:127-135.

STUDY

Hospital discharge documentation and risk of rehospitalisation.

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

NEWSPAPER/MAGAZINE ARTICLE

Legality of technicians' involvement in medication reconciliation not clear.

Thompson CA. AJHP News. Am J Health Syst Pharm. 2009;66:433-434.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2006;41:1148-1151.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2007;42:181–182.

STUDY

Results of the Medications At Transitions and Clinical Handoffs (MATCH) study: an analysis of medication reconciliation errors and risk factors at hospital admission.

Gleason KM, McDaniel MR, Feinglass J, et al. J Gen Intern Med. 2010;25:441-447.

STUDY

Pharmacist medication assessments in a surgical preadmission clinic.

Kwan Y, Fernandes OA, Nagge JJ, et al. Arch Intern Med. 2007;167:1034-1040.

BOOK/REPORT

Improving America's Hospitals: The Joint Commission's Report on Quality and Safety 2008.

Oakbrook Terrace, IL: The Joint Commission; November 2008.

STUDY

Prescribing discrepancies likely to cause adverse drug events after patient transfer.

Boockvar KS, Liu S, Goldstein N, Nebeker J, Siu A, Fried T. Qual Saf Health Care. 2009;18:32-36.

STUDY

Clinical and safety impact of an inpatient pharmacist-directed anticoagulation service.

Schillig J, Kaatz S, Hudson M, Krol GD, Szandzik EG, Kalus JS. J Hosp Med. 2011;6:322-328.

TOOLKIT

Medications at Transitions and Clinical Handoffs (MATCH) Medication Reconciliation Toolkit.

Chicago, IL: Northwestern Memorial Hospital; 2007.

COMMENTARY

Medication reconciliation in a community, nonteaching hospital.

Wortman SB. Am J Health Syst Pharm. 2008;65:2047-2054.

STUDY

Medication reconciliation for reducing drug-discrepancy adverse events.

Boockvar KS, Carlson Lacorte H, Giambanco V, Fridman B, Siu A. Am J Geriatr Pharmacother. 2006;4:236-243.

COMMENTARY

The challenge of medication reconciliation.

Patient Safety & Quality Healthcare. May 10, 2006.

NEWSPAPER/MAGAZINE ARTICLE

Survey results: community liaison programs to decrease hospital readmissions.

ISMP Medication Safey Alert! Acute Care Edition. March 7, 2013;18:1-3.

NEWSPAPER/MAGAZINE ARTICLE

Practitioners agree on medication reconciliation value, but frustration and difficulties abound.

ISMP Medication Safety Alert! Acute Care Edition. July 13, 2006;11:1-2.

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