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 (14)

Origin/Sponsor

•Africa (1)

•Asia (2)

•Australia and New Zealand (11)

Resource Types

•Journal Article (251)

•Legislation/Regulation (10)

•Newspaper/Magazine Article (27)

•Special or Theme Issue (3)

•Tools/Toolkit (2)

•Web Resource (4)

Error Types

•Epidemiology of Errors and Adverse Events (64)

•Active Errors (77)

•Latent Errors (90)

•Near Miss (5)

Approach to Improving Safety

•Quality Improvement Strategies (93)

•Legal and Policy Approaches (25)

•Error Reporting and Analysis (62)

•Communication Improvement (206)

•Human Factors Engineering (33)

•Teamwork (25)

•Specialization of Care (29)

•Logistical Approaches (64)

•Culture of Safety (22)

•Technologic Approaches (51)

•Education and Training (79)

Clinical Areas

•Allied Health Services (3)

•Medicine (257)

•Nursing (31)

•Pharmacy (23)

Target Audience

•Health Care Providers (262)

•Health Care Executives and Administrators (239)

•Non-Health Care Professionals (88)

•Patients (19)

Setting of Care

•Hospitals (213)

•Psychiatric Facilities (2)

•Residential Facilities (7)

•Ambulatory Care (47)

•Outpatient Surgery (3)

•Patient Transport (9)

1 - 20 of 315

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NEWSPAPER/MAGAZINE ARTICLE

What's the trouble? How doctors think.

Groopman J. The New Yorker. January 29, 2007;47:36-41.

STUDY

Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims.

Gandhi TK, Kachalia A, Thomas EJ, et al. Ann Intern Med. 2006;145:488-496.

STUDY

The importance of establishing regimen concordance in preventing medication errors in anticoagulant care.

Schillinger D, Wang F, Rodriguez M, Bindman A, Machtinger EL. J Health Comm. 2006;11:555-567.

COMMENTARY

Delay in Initiating Antibiotics Leads to Fatal Error.

Bellini LM. AHRQ WebM&M [serial online]. February 2004.

COMMENTARY

Citrate Mix-Up

Weber RJ. AHRQ WebM&M [serial online]. May 2006.

STUDY

Diagnostic pitfalls in paediatric ischaemic stroke.

Braun KP, Kappelle LJ, Kirkham FJ, Deveber G. Dev Med Child Neurol. 2006;48:985-990.

COMMENTARY

Deciphering the Code

Goldstein MK. AHRQ WebM&M [serial online]. Febuary 2006.

BOOK/REPORT

Breast Cancer Services in Trafford and North Manchester. An Investigation Into The Circumstances Surrounding A Serious Clinical Incident In Symptomatic Breast Services – The Baker Report.

Baker M. Manchester, England: NHS North West; February 2007.

COMMENTARY

Missed Appendicitis.

Adams JG. AHRQ WebM&M [serial online]. June 2003.

COMMENTARY

Triage Time Bomb.

Washington DL. AHRQ WebM&M [serial online]. January 2004.

STUDY

Risk of medication errors at hospital discharge and barriers to problem resolution.

Enguidanos SM, Brumley RD. Home Health Care Serv Q. 2005;24:123-135.

COMMENTARY

The Dangerous Detour.

Gibson J, Taylor D. AHRQ WebM&M [serial online]. June 2003.

COMMENTARY

Physical Diagnosis: A Lost Art?

Thompson GR, Verghese A. AHRQ WebM&M [serial online]. August 2006.

COMMENTARY

Hidden Mystery.

Brunette DD. AHRQ WebM&M [serial online]. March 2005.

COMMENTARY

Crossed Coverage

Kayser SR. AHRQ WebM&M [serial online]. February 2007.

STUDY

Insufficient communication about medication use at the interface between hospital and primary care.

Glintborg B, Andersen SE, Dalhoff K. Qual Saf Health Care. 2007;16:34-39.

STUDY

Delayed or missed diagnosis of cervical spine injuries.

Platzer P, Hauswirth N, Jaindl M, Chatwani S, Vecsei V, Gaebler C. J Trauma. 2006;61:150-155.

STUDY

Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers.

Kachalia A, Gandhi TK, Puopolo AL, et al. Ann Emerg Med. Ann Emerg Med. 2007;49:196-205.

STUDY

The effects of on-duty napping on intern sleep time and fatigue.

Arora V, Dunphy C, Chang VY, Ahmad F, Humphrey HJ, Meltzer D. Ann Intern Med. 2006;144:792-798.

COMMENTARY

Lost in Transition

Beach C. AHRQ WebM&M [serial online]. Febuary 2006.

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