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 (26)

Origin/Sponsor

•Asia (3)

•Australia and New Zealand (16)

Resource Types

•Journal Article (510)

•Legislation/Regulation (11)

•Meeting/Conference (1)

•Newspaper/Magazine Article (71)

•Special or Theme Issue (15)

•Tools/Toolkit (8)

•Web Resource (13)

•Grant (3)

Error Types

•Epidemiology of Errors and Adverse Events (135)

•Active Errors (107)

•Latent Errors (74)

•Near Miss (4)

Approach to Improving Safety

•Quality Improvement Strategies (124)

•Legal and Policy Approaches (48)

•Error Reporting and Analysis (97)

•Communication Improvement (435)

•Human Factors Engineering (58)

•Teamwork (55)

•Specialization of Care (62)

•Logistical Approaches (108)

•Culture of Safety (42)

•Technologic Approaches (115)

•Education and Training (160)

Clinical Areas

•Allied Health Services (3)

•Medicine (501)

•Nursing (61)

•Pharmacy (59)

Target Audience

•Health Care Providers (476)

•Health Care Executives and Administrators (495)

•Non-Health Care Professionals (208)

•Patients (52)

Setting of Care

•Hospitals (510)

•Psychiatric Facilities (3)

•Residential Facilities (18)

•Ambulatory Care (92)

•Outpatient Surgery (5)

•Patient Transport (12)

1 - 20 of 664

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STUDY

Residents' perspectives on ACGME regulation of supervision and duty hours—a national survey.

Drolet BC, Spalluto LB, Fischer SA. N Engl J Med. 2010;363:e34.

STUDY

Cost implications of ACGME's 2011 changes to resident duty hours and the training environment.

Nuckols TK, Escarce JJ. J Gen Intern Med. 2012;27:241-249.

STUDY

Cost implications of reduced work hours and workloads for resident physicians.

Nuckols TK, Bhattacharya J, Miller Wolman D, Ulmer C, Escarce JJ. N Engl J Med. 2009;360:2202-2215.

COMMENTARY

The ACGME’s final duty-hour standards—special PGY-1 limits and strategic napping.

Iglehart JK. N Engl J Med. 2010;363:1589-1591.

COMMENTARY classic

The new recommendations on duty hours from the ACGME Task Force.

Nasca TJ, Day SH, Amis ES Jr; for ACGME Duty Hours Task Force. N Engl J Med. 2010;363:e3.

MULTI-USE WEBSITE

Quality Care and Excellence in Medical Education.

Accreditation Council for Graduate Medical Education.

COMMENTARY

Revisiting duty-hour limits — IOM recommendations for patient safety and resident education.

Iglehart JK. N Engl J Med. 2008;359:2633-2635.

STUDY

ACGME duty-hour recommendations—a national survey of residency program directors.

Antiel RM, Thompson SM, Reed DA, et al. N Engl J Med. 2010;363:e12.

COMMENTARY

An elusive balance — residents' work hours and the continuity of care.

Okie S. N Engl J Med. 2007;356:2665-2667.

REVIEW

Effects of reducing or eliminating resident work shifts over 16 hours: a systematic review.

Levine AC, Adusumilli J, Landrigan CP. Sleep. 2010;33:1043-1053.

COMMENTARY

For whom the Bell Commission tolls: unintended effects of limiting residents' hours.

Millard WB. Ann Emerg Med. 2009;54:A25-A29.

STUDY

Changes in outcomes for internal medicine inpatients after work-hour regulations.

Horwitz LI, Kosiborod M, Lin Z, Krumholz HM. Ann Intern Med. 2007;147:97-103.

STUDY

Association of workload of on-call medical interns with on-call sleep duration, shift duration, and participation in educational activities.

Arora VM, Georgitis E, Siddique J, et al. JAMA. 2008;300:1146-1153.

STUDY

Changes in hospital mortality associated with residency work-hour regulations.

Shetty KD, Bhattacharya J. Ann Intern Med. 2007;147:73-80.

COMMENTARY

Building physician work hour regulations from first principles and best evidence.

Volpp KG, Landrigan CP. JAMA. 2008;300:1197-1199.

COMMENTARY

Putting the sleepy resident issue to bed: federal legislation is not the answer to excessive medical resident working hours.

Stone JD. Suffolk Univ Law Rev. 2007;40:745-767.

COMMENTARY

Do Not Disturb!

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

REVIEW

Myths and realities of the 80-hour work week.

Schenarts PJ, Anderson Schenarts KD, Rotondo MF. Curr Surg. 2006;63:269-274.

REVIEW

Impact of reduction in working hours for doctors in training on postgraduate medical education and patients' outcomes: systematic review.

Moonesinghe SR, Lowery J, Shahi N, Millen A, Beard JD. BMJ. 2011;342:d1580.

STUDY

Predicting future staffing needs at teaching hospitals: use of an analytical program with multiple variables.

Mitchell CC, Ashley SW, Zinner MJ, Moore FD. Arch Surg. 2007;142:329-334.

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