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 (15)

Origin/Sponsor

•Asia (2)

•Australia and New Zealand (27)

Resource Types

•Journal Article (445)

•Legislation/Regulation (8)

•Meeting/Conference (2)

•Newspaper/Magazine Article (41)

•Press Release/Announcement (1)

•Special or Theme Issue (12)

•Tools/Toolkit (10)

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Error Types

•Epidemiology of Errors and Adverse Events (120)

•Active Errors (107)

•Latent Errors (65)

•Near Miss (6)

Approach to Improving Safety

•Quality Improvement Strategies (125)

•Legal and Policy Approaches (36)

•Error Reporting and Analysis (90)

•Communication Improvement (392)

•Human Factors Engineering (56)

•Teamwork (50)

•Specialization of Care (47)

•Logistical Approaches (79)

•Culture of Safety (44)

•Technologic Approaches (99)

•Education and Training (123)

Clinical Areas

•Allied Health Services (4)

•Medicine (453)

•Nursing (42)

•Pharmacy (43)

Target Audience

•Health Care Providers (450)

•Health Care Executives and Administrators (461)

•Non-Health Care Professionals (181)

•Patients (32)

Setting of Care

•Hospitals (414)

•Psychiatric Facilities (4)

•Residential Facilities (16)

•Ambulatory Care (84)

•Outpatient Surgery (5)

•Patient Transport (20)

1 - 20 of 558

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STUDY

Improving communication in the emergency department.

Redfern E, Brown R, Vincent CA. Emerg Med J. 2009;26:658-661.

STUDY

Dropping the baton during the handoff from emergency department to primary care: pediatric asthma continuity errors.

Hsiao AL, Shiffman RN. Jt Comm J Qual Patient Saf. 2009;35:467-474.

STUDY

"Sign right here and you're good to go": a content analysis of audiotaped emergency department discharge instructions.

Vashi A, Rhodes KV. Ann Emerg Med. 2011;57:315-322.e1.

STUDY

Clinical handover in the trauma setting: a qualitative study of paramedics and trauma team members.

Evans SM, Murray A, Patrick I, Fitzgerald M, Smith S, Cameron P. Qual Saf Health Care. 2010;19:e57.

REVIEW

Clinical handover of patients arriving by ambulance to the emergency department: a literature review.

Bost N, Crilly J, Wallis M, Patterson E, Chaboyer W. Int Emerg Nurs. 2010;18:210-220.

STUDY

Older patients' understanding of emergency department discharge information and its relationship with adverse outcomes.

Hastings SN, Barrett A, Weinberger M, et al. J Patient Saf. 2011;7:19-25.

STUDY

'The ABC of Handover': impact on shift handover in the emergency department.

Farhan M, Brown R, Vincent C, Woloshynowych M. Emerg Med J. 2012;29:947-953.

STUDY

Information loss in emergency medical services handover of trauma patients.

Carter AJE, Davis KA, Evans LV, Cone DC. Prehosp Emerg Care. 2009;13:280-285.

NEWSPAPER/MAGAZINE ARTICLE

A hospital races to learn lessons of Ferrari pit stop.

Naik G. Wall Street Journal. November 14, 2006:A1. [reprinted on Post-gazette.com].

STUDY

Exploring emergency physician–hospitalist handoff interactions: development of the Handoff Communication Assessment.

Apker J, Mallak LA, Applegate EB 3rd, et al. Ann Emerg Med. 2010;55:161-170.

STUDY

Teamwork errors in trauma resuscitation.

Sarcevic A, Marsic I, Burd RS. ACM Trans Comput Hum Interact. 2012;19:13:1-13:30.

STUDY

Standardised proformas improve patient handover: audit of trauma handover practice.

Ferran NA, Metcalfe AJ, O'Doherty D. Patient Saf Surg. 2008;2:24.

STUDY

Assessing clinical handover between paramedics and the trauma team.

Evans SM, Murray A, Patrick I, Fitzgerald M, Smith S, Andrianopoulos N, Cameron P. Injury. 2010;36:100-106.

STUDY

Unplanned transfers to a medical intensive care unit: causes and relationship to preventable errors in care.

Bapoje SR, Gaudiani JL, Narayanan V, Albert RK. J Hosp Med. 2011;6:68-72.

STUDY

ED handoffs: observed practices and communication errors.

Maughan BC, Lei L, Cydulka RK. Am J Emerg Med. 2011;29:502-511.

STUDY

Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality.

Catchpole KR, de Leval MR, McEwan A, et al. Paediatr Anaesth. 2007;17:470-478.

NEWSPAPER/MAGAZINE ARTICLE

Patient safety records: silent witness.

Gould M. Health Service Journal. September 15, 2008:22-24.

COMMENTARY

Triage Time Bomb.

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

STUDY

Use of failure mode and effects analysis for proactive identification of communication and handoff failures from organ procurement to transplantation.

Steinberger DM, Douglas SV, Kirschbaum MS. Prog Transplant. 2009;19:208-215.

COMMENTARY

Missed Appendicitis.

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

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