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 (25)

Origin/Sponsor

•Asia (2)

•Australia and New Zealand (23)

Resource Types

•Journal Article (510)

•Legislation/Regulation (10)

•Meeting/Conference (2)

•Newspaper/Magazine Article (74)

•Special or Theme Issue (9)

•Tools/Toolkit (10)

•Web Resource (16)

•Grant (2)

Error Types

•Epidemiology of Errors and Adverse Events (155)

•Active Errors (99)

•Latent Errors (61)

•Near Miss (4)

Approach to Improving Safety

•Quality Improvement Strategies (128)

•Legal and Policy Approaches (40)

•Error Reporting and Analysis (104)

•Communication Improvement (442)

•Human Factors Engineering (58)

•Teamwork (46)

•Specialization of Care (53)

•Logistical Approaches (101)

•Culture of Safety (36)

•Technologic Approaches (115)

•Education and Training (142)

Clinical Areas

•Allied Health Services (3)

•Medicine (504)

•Nursing (57)

•Pharmacy (71)

Target Audience

•Health Care Providers (472)

•Health Care Executives and Administrators (501)

•Non-Health Care Professionals (190)

•Patients (48)

Setting of Care

•Hospitals (483)

•Psychiatric Facilities (2)

•Residential Facilities (20)

•Ambulatory Care (89)

•Outpatient Surgery (5)

•Patient Transport (13)

1 - 20 of 661

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STUDY

Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study.

Walker PC, Bernstein SJ, Tucker Jones JN, et al. Arch Intern Med. 2009;169:2003-2010.

STUDY

Impact of a pharmacist on medication reconciliation on patient admission to a Veterans Affairs Medical Center.

Strunk LB, Matson AW, Steinke D. Hosp Pharm. 2008;43:643-649.

STUDY

Clinical and safety impact of an inpatient pharmacist-directed anticoagulation service.

Schillig J, Kaatz S, Hudson M, Krol GD, Szandzik EG, Kalus JS. J Hosp Med. 2011;6:322-328.

COMMENTARY

Medication reconciliation in a community, nonteaching hospital.

Wortman SB. Am J Health Syst Pharm. 2008;65:2047-2054.

STUDY

Results of the Medications At Transitions and Clinical Handoffs (MATCH) study: an analysis of medication reconciliation errors and risk factors at hospital admission.

Gleason KM, McDaniel MR, Feinglass J, et al. J Gen Intern Med. 2010;25:441-447.

STUDY

The effect on medication errors of pharmacists charting medication in an emergency department.

Vasileff HM, Whitten LE, Pink JA, Goldsworthy SJ, Angley MT. Pharm World Sci. 2009;31:373-379.

STUDY

Medication reconciliation performed by pharmacy technicians at the time of preoperative screening.

van den Bemt PM, van den Broek S, van Nunen AK, Harbers JB, Lenderink AW. Ann Pharmacother. 2009;43:868-874.

STUDY

Reducing medication errors and improving systems reliability using an electronic medication reconciliation system.

Agrawal A, Wu WY. Jt Comm J Qual Patient Saf. 2009;35:106-114.

COMMENTARY

Ten years after the IOM report: engaging residents in quality and patient safety by creating a house staff quality council.

Fleischut PM, Evans AS, Nugent WC, et al. Am J Med Qual. 2011;26:89-94.

NEWSPAPER/MAGAZINE ARTICLE

Legality of technicians' involvement in medication reconciliation not clear.

Thompson CA. AJHP News. Am J Health Syst Pharm. 2009;66:433-434.

STUDY

Pharmacist medication assessments in a surgical preadmission clinic.

Kwan Y, Fernandes OA, Nagge JJ, et al. Arch Intern Med. 2007;167:1034-1040.

COMMENTARY

Implementing online medication reconciliation at a large academic medical center.

Bails D, Clayton K, Roy K, Cantor MN. Jt Comm J Qual Patient Saf. 2008;34:499-508.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2009;44:463-464.

STUDY

Medication reconciliation for reducing drug-discrepancy adverse events.

Boockvar KS, Carlson Lacorte H, Giambanco V, Fridman B, Siu A. Am J Geriatr Pharmacother. 2006;4:236-243.

STUDY

Discrepancies between home medications listed at hospital admission and reported medical conditions.

Slain D, Kincaid SE, Dunsworth TS. Am J Geriatr Pharmacother. 2008;6:161-166.

STUDY

Challenges in posthospital care: nurses as coaches for medication management.

Costa LL, Poe SS, Lee MC. J Nurs Care Qual. 2011;26:243-251.

STUDY

Implementation of an electronic system for medication reconciliation.

Kramer JS, Hopkins PJ, Rosendale JC, et al. Am J Health Syst Pharm. 2007;64:404-422.

COMMENTARY

Implementation of a specialized pharmacy team to monitor high-risk medications during discharge.

Martin ES III, Overstreet RL, Jackson-Khalil LR, McCollough HL, Meyer TA, Xu Q. Am J Health Syst Pharm. 2013;70:18-21.

COMMENTARY

Medication reconciliation physician order form.

Lacy JL, Wilkinson ST. Hosp Pharm. 2006;41:1117-1120.

STUDY

Medication discrepancies upon hospital to skilled nursing facility transitions.

Tjia J, Bonner A, Briesacher BA, McGee S, Terrill E, Miller K. J Gen Intern Med. 2009;24:630-635.

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