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 (40)

Origin/Sponsor

•Africa (1)

•Asia (5)

•Australia and New Zealand (26)

Resource Types

•Journal Article (513)

•Legislation/Regulation (10)

•Meeting/Conference (1)

•Newspaper/Magazine Article (60)

•Press Release/Announcement (1)

•Special or Theme Issue (13)

•Tools/Toolkit (12)

•Web Resource (14)

•Grant (4)

Error Types

•Epidemiology of Errors and Adverse Events (131)

•Active Errors (135)

•Latent Errors (82)

•Near Miss (6)

Approach to Improving Safety

•Quality Improvement Strategies (152)

•Legal and Policy Approaches (50)

•Error Reporting and Analysis (96)

•Communication Improvement (457)

•Human Factors Engineering (59)

•Teamwork (56)

•Specialization of Care (56)

•Logistical Approaches (113)

•Culture of Safety (44)

•Technologic Approaches (125)

•Education and Training (157)

Clinical Areas

•Allied Health Services (4)

•Medicine (517)

•Nursing (49)

•Pharmacy (50)

Target Audience

•Health Care Providers (515)

•Health Care Executives and Administrators (480)

•Non-Health Care Professionals (195)

•Patients (51)

Setting of Care

•Hospitals (496)

•Psychiatric Facilities (4)

•Residential Facilities (18)

•Ambulatory Care (111)

•Outpatient Surgery (5)

•Patient Transport (16)

1 - 20 of 660

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COMMENTARY

The Dropped Lung.

Heffner JE. AHRQ WebM&M [serial online]. May 2003.

COMMENTARY

Premature or Overdue?

Thomas J, Hannah M. AHRQ WebM&M [serial online]. April 2003.

COMMENTARY

Undiagnosed Vaginal Bleeding.

Mandelblatt J. AHRQ WebM&M [serial online]. February 2004.

COMMENTARY

Do Me a Favor.

Williamson A. AHRQ WebM&M [serial online]. May 2004.

COMMENTARY

Missed Appendicitis.

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

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

The Result Stopped Here.

Astion M. AHRQ WebM&M [serial online]. June 2004.

COMMENTARY

Do Not Disturb!

Duffy FD, Cassel CK. AHRQ WebM&M [serial online]. October 2007.

COMMENTARY

Preventable Rash.

McLean C. AHRQ WebM&M [serial online]. March 2005.

COMMENTARY

Ruptured Heterotopic Pregnancy.

Cedars MI. AHRQ WebM&M [serial online]. January 2004.

COMMENTARY

Discharge Fumbles.

Forster A. AHRQ WebM&M [serial online]. December 2004.

COMMENTARY

A "Weak" Response.

Reisman AB. AHRQ WebM&M [serial online]. December 2004.

COMMENTARY

Failure to Latch

Rodriguez M., Mannel R., Frye D. MN AHRQ WebM&M [serial online]. September 2008.

STUDY

Radiologists' responses to inadequate referrals.

Lysdahl KB, Hofmann BM, Espeland A. Eur Radiol. 2010;20:1227-1233.

COMMENTARY

Elopement

Gerardi D. AHRQ WebM&M [serial online]. December 2007.

ORGANIZATIONAL POLICY/GUIDELINES

ACOG Committee Opinion #472: patient safety and the electronic health record.

ACOG Committee on Patient Safety and Quality Improvement. Obstet Gynecol. 2010;116:1245-1247.

COMMENTARY

Glucose Roller Coaster.

Sharpe BA. AHRQ WebM&M [serial online]. July 2004.

COMMENTARY

To LP or not LP.

Landrigan CP. AHRQ WebM&M [serial online]. October 2003.

COMMENTARY

Waiting Too Long.

Rosen MA. AHRQ WebM&M [serial online]. November 2003.

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