AHRQ Patient Safety Network

The Collection > Discontinuities, Gaps, and Hand-Off Problems

PATIENT SAFETY PRIMERS
Adverse Events after Hospital Discharge
Handoffs and Signouts

Narrow By

clear selections

Safety Target
< All

Discontinuities, Gaps, and Hand-Off Problems

•Missed or Critical Lab Results (59)

Origin/Sponsor

•Africa (1)

•Asia (3)

•Australia and New Zealand (29)

Resource Types

•Journal Article (617)

•Legislation/Regulation (10)

•Meeting/Conference (2)

•Newspaper/Magazine Article (76)

•Special or Theme Issue (14)

•Tools/Toolkit (12)

•Web Resource (16)

•Grant (2)

Error Types

•Epidemiology of Errors and Adverse Events (189)

•Active Errors (130)

•Latent Errors (82)

•Near Miss (8)

Approach to Improving Safety

•Quality Improvement Strategies (158)

•Legal and Policy Approaches (52)

•Error Reporting and Analysis (124)

•Communication Improvement (505)

•Human Factors Engineering (68)

•Teamwork (59)

•Specialization of Care (62)

•Logistical Approaches (131)

•Culture of Safety (46)

•Technologic Approaches (144)

•Education and Training (171)

Clinical Areas

•Allied Health Services (5)

•Medicine (610)

•Nursing (64)

•Pharmacy (68)

Target Audience

•Health Care Providers (571)

•Health Care Executives and Administrators (571)

•Non-Health Care Professionals (224)

•Patients (55)

Setting of Care

•Hospitals (553)

•Psychiatric Facilities (4)

•Residential Facilities (22)

•Ambulatory Care (120)

•Outpatient Surgery (5)

•Patient Transport (18)

1 - 20 of 777

Show ExcerptDon't Show Excerpt

dropdown

STUDY

Electronic medical record availability and primary care depression treatment.

Harman JS, Rost KM, Harle CA, Cook RL. J Gen Intern Med. 2012;27:962-967.

STUDY

Improving medication reconciliation in the outpatient setting.

Varkey P, Cunningham J, Bisping S. Jt Comm J Qual Patient Saf. 2007;33:286-292.

STUDY

The care transitions intervention: translating from efficacy to effectiveness.

Voss R, Gardner R, Baier R, Butterfield K, Lehrman S, Gravenstein S. Arch Intern Med. 2011;171:1232-1237.

STUDY

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

Altfeld SJ, Shier GE, Rooney M, et al. Gerontologist. 2012 Sep 7; [Epub ahead of print].

STUDY

Frequency of failure to inform patients of clinically significant outpatient test results.

Casalino LP, Dunham D, Chin MH, et al. Arch Intern Med. 2009;169:1123-1129.

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

Post-discharge medication reviews for patients with heart failure: a pilot study.

Ponniah A, Shakib S, Doecke CJ, Boyce M, Angley M. Pharm World Sci. 2008;30:810-815.

STUDY

Hospital discharge documentation and risk of rehospitalisation.

Hansen LO, Strater A, Smith L, et al. BMJ Qual Saf. 2011;20:773-778.

STUDY

Are opioid dependence and methadone maintenance treatment (MMT) documented in the medical record? A patient safety issue.

Walley AY, Farrar D, Cheng DM, Alford DP, Samet JH. J Gen Intern Med. 2009;24:1007-1011.

STUDY

Patient safety in after-hours telephone medicine.

Killip S, Ireson CL, Love MM, Fleming ST, Katirai W, Sandford K. Fam Med. 2007;39:404-409.

STUDY

New 2011 survey of patients with complex care needs in eleven countries finds that care is often poorly coordinated.

Schoen C, Osborn R, Squires D, Doty M, Pierson R, Applebaum S. Health Aff (Millwood). 2011;30:2437-2448.

REVIEW

Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care.

Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. JAMA. 2007;297:831-841.

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.

ORGANIZATIONAL POLICY/GUIDELINES

Transitions of Care Consensus Policy Statement American College of Physicians-Society of General Internal Medicine-Society of Hospital Medicine-American Geriatrics Society-American College of Emergency Physicians-Society of Academic Emergency Medicine.

Snow V, Beck D, Budnitz T, et al. J Gen Intern Med. 2009;24:971-976.

AUDIOVISUAL

Healthcare 411: Making hospital discharges safer for seniors.

Rockville, MD: Agency for Healthcare Research and Quality. June 3, 2009.

STUDY

Direct reporting of laboratory test results to patients by mail to enhance patient safety.

Sung S, Forman-Hoffman V, Wilson MC, Cram P. J Gen Intern Med. 2006;21:1075-78.

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.

MULTI-USE WEBSITE

Getting Safer Care.

Agency for Healthcare Research and Quality.

REVIEW

Coordinating care across diseases, settings, and clinicians: a key role for the generalist in practice.

Stille CJ, Jerant A, Bell D, Meltzer D, Elmore JG. Ann Intern Med. 2005;142:700-708.

STUDY

Missed opportunities in the primary care management of early acute ischemic heart disease.

Sequist TD, Marshall R, Lampert S, Buechler EJ, Lee TH. Arch Intern Med. 2006;166:2237-2243.

1 2 3 4 5 6 7 8 9 10 11 Next >