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 (53)

Origin/Sponsor

•Asia (4)

•Australia and New Zealand (30)

Resource Types

•Journal Article (589)

•Legislation/Regulation (11)

•Meeting/Conference (1)

•Newspaper/Magazine Article (78)

•Special or Theme Issue (11)

•Tools/Toolkit (8)

•Web Resource (16)

•Grant (3)

Error Types

•Epidemiology of Errors and Adverse Events (165)

•Active Errors (127)

•Latent Errors (82)

•Near Miss (8)

Approach to Improving Safety

•Quality Improvement Strategies (146)

•Legal and Policy Approaches (47)

•Error Reporting and Analysis (111)

•Communication Improvement (494)

•Human Factors Engineering (71)

•Teamwork (60)

•Specialization of Care (65)

•Logistical Approaches (133)

•Culture of Safety (41)

•Technologic Approaches (140)

•Education and Training (161)

Clinical Areas

•Allied Health Services (4)

•Medicine (577)

•Nursing (66)

•Pharmacy (70)

Target Audience

•Health Care Providers (538)

•Health Care Executives and Administrators (557)

•Non-Health Care Professionals (227)

•Patients (52)

Setting of Care

•Hospitals (554)

•Psychiatric Facilities (3)

•Residential Facilities (19)

•Ambulatory Care (111)

•Outpatient Surgery (5)

•Patient Transport (16)

1 - 20 of 747

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STUDY

Evaluation of a physician informatics tool to improve patient handoffs.

Flanagan ME, Patterson ES, Frankel RM, Doebbeling BN. J Am Med Inform Assoc. 2009;16:509-515.

COMMENTARY

Handoffs in the era of duty hours reform: a focused review and strategy to address changes in the Accreditation Council for Graduate Medical Education Common Program Requirements.

DeRienzo CM, Frush K, Barfield ME, et al. Acad Med. 2012;87:403-410.

STUDY

Impact of resident workload and handoff training on patient outcomes.

Mueller SK, Call SA, McDonald FS, Halvorsen AJ, Schnipper JL, Hicks LS. Am J Med. 2012;125:104-110.

STUDY

Safety of using a computerized rounding and sign-out system to reduce resident duty hours.

Van Eaton EG, McDonough K, Lober WB, Johnson EA, Pellegrini CA, Horvath KD. Acad Med. 2010;85:1189-1195.

COMMENTARY

Fumbled Handoff.

Vidyarthi A. AHRQ WebM&M [serial online]. March 2004.

STUDY

Measuring handoff quality in labor and delivery: development, validation, and application of the Coordination of Handoff Effectiveness Questionnaire (CHEQ).

Block M, Ehrenworth JF, Cuce VM, et al. Jt Comm J Qual Patient Saf. 2013;39:213-220.

REVIEW

Research on nursing handoffs for medical and surgical settings: an integrative review.

Staggers N, Blaz JW. J Adv Nurs. 2013;69:247-262.

COMMENTARY

Time to sign off on signout.

Stein DM, Stetson PD. Acad Med. 2011;86:804-806.

STUDY

The computerized rounding report: implementation of a model system to support transitions of care.

Wohlauer MV, Rove KO, Pshak TJ, et al. J Surg Res. 2012;172:11-17.

STUDY

Multi-professional patterns and methods of communication during patient handoffs.

Benham-Hutchins MM, Effken JA. Int J Med Inform. 2010;79:252-267.

COMMENTARY

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

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

STUDY

Use of an appreciative inquiry approach to improve resident sign-out in an era of multiple shift changes.

Helms AS, Perez TE, Baltz J, et al. J Gen Intern Med. 2012;27:287-291.

TOOLS/TOOLKIT

Improving Transitions of Care: Hand-off Communications.

Oakbrook Terrace, IL: Joint Commission Center for Transforming Healthcare; June 2012.

COMMENTARY

Academic year-end transfers of outpatients from outgoing to incoming residents: an unaddressed patient safety issue.

Young JQ, Wachter RM. JAMA. 2009;302:1327-1329.

COMMENTARY

2009 National Patient Safety Goals.

Saufl NM. J Perianesth Nurs. 2009;24:114-118.

STUDY

Why patient summaries in electronic health records do not provide the cognitive support necessary for nurses' handoffs on medical and surgical units: insights from interviews and observations.

Staggers N, Clark L, Blaz JW, Kapsandoy S. Health Informatics J. 2011;17:209-223.

STUDY

Implementing peer evaluation of handoffs: associations with experience and workload.

Arora VM, Greenstein EA, Woodruff JN, Staisiunas PG, Farnan JM. J Hosp Med. 2013;8:132-136.

STUDY

An institution-wide handoff task force to standardise and improve physician handoffs.

Horwitz LI, Schuster KM, Thung SF, et al. BMJ Qual Saf. 2012;21:863-871.

REVIEW

Hospitalist handoffs: a systematic review and task force recommendations.

Arora VM, Manjarrez E, Dressler DD, Basaviah P, Halasyamani L, Kripalani S. J Hosp Med. 2009;4:433-440.

STUDY

What are covering doctors told about their patients? Analysis of sign-out among internal medicine house staff.

Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. Qual Saf Health Care. 2009;18:248-255.

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