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 (67)

Origin/Sponsor

•Africa (1)

•Asia (4)

•Australia and New Zealand (31)

Resource Types

•Journal Article (632)

•Legislation/Regulation (10)

•Meeting/Conference (2)

•Newspaper/Magazine Article (79)

•Special or Theme Issue (15)

•Tools/Toolkit (13)

•Web Resource (17)

•Grant (3)

Error Types

•Epidemiology of Errors and Adverse Events (190)

•Active Errors (137)

•Latent Errors (91)

•Near Miss (8)

Approach to Improving Safety

•Quality Improvement Strategies (162)

•Legal and Policy Approaches (50)

•Error Reporting and Analysis (127)

•Communication Improvement (518)

•Human Factors Engineering (69)

•Teamwork (63)

•Specialization of Care (67)

•Logistical Approaches (140)

•Culture of Safety (47)

•Technologic Approaches (153)

•Education and Training (173)

Clinical Areas

•Allied Health Services (4)

•Medicine (624)

•Nursing (69)

•Pharmacy (68)

Target Audience

•Health Care Providers (581)

•Health Care Executives and Administrators (587)

•Non-Health Care Professionals (241)

•Patients (54)

Setting of Care

•Hospitals (568)

•Psychiatric Facilities (4)

•Residential Facilities (21)

•Ambulatory Care (118)

•Outpatient Surgery (5)

•Patient Transport (18)

1 - 20 of 798

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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.

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

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

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.

STUDY

Patient whiteboards as a communication tool in the hospital setting: A survey of practices and recommendations.

Sehgal NL, Green A, Vidyarthi AR, Blegen MA, Wachter RM. J Hosp Med. 2010;5:234-239.

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

Physician reporting of clinically significant events through a computerized patient sign-out system.

Nabors C, Peterson SJ, Aronow WS, et al. J Patient Saf. 2011;7:154-160.

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.

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.

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

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.

COMMENTARY

Utilizing information technology to mitigate the handoff risks caused by resident work hour restrictions.

Bernstein J, MacCourt DC, Jacob DM, Mehta S. Clin Orthop Relat Res. 2010;468:2627-2732.

STUDY

The Veterans Affairs shift change physician-to-physician handoff project.

Anderson J, Shroff D, Curtis A, et al. Jt Comm J Qual Patient Saf. 2010;36:62-71.

STUDY

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

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

STUDY

Medication reconciliation: barriers and facilitators from the perspectives of resident physicians and pharmacists.

Boockvar KS, Santos SL, Kushniruk A, Johnson C, Nebeker JR. J Hosp Med. 2011;6:329-337.

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.

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

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

Medication safety initiative in reducing medication errors.

Nguyen EE, Connolly PM, Wong V. J Nurs Care Qual. 2010;25:224-230.

STUDY

The association between transfer of emergency department boarders to inpatient hallways and mortality: a 4-year experience.

Viccellio A, Santora C, Singer AJ, Thode HC Jr, Henry MC. Ann Emerg Med. 2009;54:511-513.

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