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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
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Missed or Critical Lab Results (36)
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COMMENTARY
Missed Appendicitis.
Adams JG. AHRQ WebM&M [serial online]. June 2003.
COMMENTARY
Lethal Vertigo.
Furman JM. AHRQ WebM&M [serial online]. June 2004.
COMMENTARY
Not a Miscarriage.
Learman LA. AHRQ WebM&M [serial online]. June 2003.
COMMENTARY
The Dropped Lung.
Heffner JE. AHRQ WebM&M [serial online]. May 2003.
COMMENTARY
To LP or not LP.
Landrigan CP. AHRQ WebM&M [serial online]. October 2003.
COMMENTARY
Ruptured Heterotopic Pregnancy.
Cedars MI. AHRQ WebM&M [serial online]. January 2004.
COMMENTARY
Language Barrier
Flores G. AHRQ WebM&M [serial online]. April 2006.
COMMENTARY
A "Weak" Response.
Reisman AB. AHRQ WebM&M [serial online]. December 2004.
COMMENTARY
Triage Time Bomb.
Washington DL. AHRQ WebM&M [serial online]. January 2004.
COMMENTARY
Urine a Tough Position.
Gandhi TK. AHRQ WebM&M [serial online]. October 2003.
COMMENTARY
Suicidal Man with Gun.
Simon RI. AHRQ WebM&M [serial online]. May 2003.
COMMENTARY
Recurrent Hypoglycemia: A Care Transition Failure?
Eytan T. AHRQ WebM&M [serial online]. October 2008.
COMMENTARY
Premature or Overdue?
Thomas J, Hannah M. AHRQ WebM&M [serial online]. April 2003.
NEWSPAPER/MAGAZINE ARTICLE
Inquiry into reporter's death finds multiple failures in care.
Stout D. New York Times. June 17, 2006;National desk:9.
COMMENTARY
The Dangerous Detour.
Gibson J, Taylor D. AHRQ WebM&M [serial online]. June 2003.
COMMENTARY
Delay in Initiating Antibiotics Leads to Fatal Error.
Bellini LM. AHRQ WebM&M [serial online]. February 2004.
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.
COMMENTARY
Discharge Fumbles.
Forster A. AHRQ WebM&M [serial online]. December 2004.
REVIEW
Effective discharge communication in the emergency department.
Samuels-Kalow ME, Stack AM, Porter SC. Ann Emerg Med. 2012;60:152-159.
COMMENTARY
Failure to Latch
Rodriguez M., Mannel R., Frye D. MN AHRQ WebM&M [serial online]. September 2008.
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