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 (55)

Origin/Sponsor

•Africa (1)

•Asia (4)

•Australia and New Zealand (31)

Resource Types

•Journal Article (613)

•Legislation/Regulation (10)

•Meeting/Conference (2)

•Newspaper/Magazine Article (78)

•Special or Theme Issue (14)

•Tools/Toolkit (13)

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Error Types

•Epidemiology of Errors and Adverse Events (193)

•Active Errors (133)

•Latent Errors (89)

•Near Miss (7)

Approach to Improving Safety

•Quality Improvement Strategies (157)

•Legal and Policy Approaches (47)

•Error Reporting and Analysis (126)

•Communication Improvement (511)

•Human Factors Engineering (67)

•Teamwork (62)

•Specialization of Care (66)

•Logistical Approaches (131)

•Culture of Safety (46)

•Technologic Approaches (141)

•Education and Training (167)

Clinical Areas

•Allied Health Services (4)

•Medicine (611)

•Nursing (67)

•Pharmacy (66)

Target Audience

•Health Care Providers (571)

•Health Care Executives and Administrators (575)

•Non-Health Care Professionals (225)

•Patients (53)

Setting of Care

•Hospitals (559)

•Psychiatric Facilities (4)

•Residential Facilities (20)

•Ambulatory Care (113)

•Outpatient Surgery (6)

•Patient Transport (20)

1 - 20 of 776

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REVIEW

Information transfer and communication in surgery: a systematic review.

Nagpal K, Vats A, Lamb B, et al. Ann Surg. 2010;252:225-239.

STUDY

An evaluation of information transfer through the continuum of surgical care: a feasibility study.

Nagpal K, Vats A, Ahmed K, Vincent C, Moorthy K. Ann Surg. 2010;252:402-407.

STUDY

Pilot implementation of a perioperative protocol to guide operating room-to-intensive care unit patient handoffs.

Petrovic MA, Aboumatar H, Baumgartner WA, et al. J Cardiothorac Vasc Anesth. 2012;26:11-16.

COMMENTARY

The top 10 list for a safe and effective sign-out.

Kemp CD, Bath JM, Berger J, et al. Arch Surg. 2008;143:1008-1010.

STUDY

Patterns of communication breakdowns resulting in injury to surgical patients.

Greenberg CC, Regenbogen SE, Studdert DM, et al. J Am Coll Surg. 2007;204:533-540.

STUDY

Use of failure mode and effects analysis for proactive identification of communication and handoff failures from organ procurement to transplantation.

Steinberger DM, Douglas SV, Kirschbaum MS. Prog Transplant. 2009;19:208-215.

BOOK/REPORT

Medmarx Data Report: A Chartbook of Medication Error Findings from the Perioperative Settings from 1998-2005.

Rockville, MD: United States Pharmacopeia; 2007.

STUDY

Deconstructing intraoperative communication failures.

Hu YY, Arriaga AF, Peyre SE, Corso KA, Roth EM, Greenberg CC. J Surg Res. 2012;177:37-42.

STUDY

Handing over patient care: is it just the old broken telephone game?

Zendejas B, Ali SM, Huebner M, Farley DR. J Surg Educ. 2011;68:465-471.

REVIEW

Can we make postoperative patient handovers safer? A systematic review of the literature.

Segall N, Bonifacio AS, Schroeder RA, et al; Durham VA Patient Safety Center of Inquiry. Anesth Analg. 2012;115:102-115.

STUDY

Handoff checklists improve the reliability of patient handoffs in the operating room and postanesthesia care unit.

Boat AC, Spaeth JP. Paediatr Anaesth. 2013 May 18; [Epub ahead of print].

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.

STUDY

Postoperative handover: problems, pitfalls, and prevention of error.

Nagpal K, Arora S, Abboudi M, et al. Ann Surg. 2010;252:171-176.

STUDY

Effects of an enhanced discharge planning intervention for hospitalized older adults: a randomized trial.

Altfeld SJ, Shier GE, Rooney M, et al. Gerontologist. 2013;53:430-440.

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

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

Uncovering system errors using a rapid response team: cross-coverage caught in the crossfire.

Kaplan LJ, Maerz LL, Schuster K, et al. J Trauma. 2009;67:173-179.

STUDY

Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care unit.

Joy BF, Elliott E, Hardy C, Sullivan C, Backer CL, Kane JM. Pediatr Crit Care Med. 2011;12:304-308.

STUDY

Quality improvement and patient care checklists in intrahospital transfers involving pediatric surgery patients.

Nakayama DK, Lester SS, Rich DR, Weidner BC, Glenn JB, Shaker IJ. J Pediatr Surg. 2012;47:112-118.

STUDY

Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication.

Lingard L, Regehr G, Orser B, et al. Arch Surg. 2008;143:12-17.

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