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 (51)

Origin/Sponsor

•Asia (3)

•Australia and New Zealand (26)

Resource Types

•Journal Article (586)

•Legislation/Regulation (11)

•Meeting/Conference (2)

•Newspaper/Magazine Article (76)

•Special or Theme Issue (15)

•Tools/Toolkit (12)

•Web Resource (14)

•Grant (4)

Error Types

•Epidemiology of Errors and Adverse Events (156)

•Active Errors (132)

•Latent Errors (86)

•Near Miss (8)

Approach to Improving Safety

•Quality Improvement Strategies (152)

•Legal and Policy Approaches (54)

•Error Reporting and Analysis (106)

•Communication Improvement (503)

•Human Factors Engineering (67)

•Teamwork (64)

•Specialization of Care (67)

•Logistical Approaches (131)

•Culture of Safety (47)

•Technologic Approaches (144)

•Education and Training (167)

Clinical Areas

•Allied Health Services (5)

•Medicine (577)

•Nursing (67)

•Pharmacy (68)

Target Audience

•Health Care Providers (565)

•Health Care Executives and Administrators (548)

•Non-Health Care Professionals (225)

•Patients (55)

Setting of Care

•Hospitals (550)

•Psychiatric Facilities (3)

•Residential Facilities (21)

•Ambulatory Care (120)

•Outpatient Surgery (6)

•Patient Transport (16)

1 - 20 of 751

Show ExcerptDon't Show Excerpt

dropdown

SPECIAL OR THEME ISSUE

How-to Guides: Improving Transitions from the Hospital to Reduce Avoidable Rehospitalizations.

Cambridge, MA: Institute for Healthcare Improvement; June 2012.

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

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.

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.

STUDY

Addressing delays in medication administration for patients transferred from the hospital to the nursing home: a pilot quality improvement project.

Ward KT, Bates-Jensen B, Eslami MS, et al. Am J Geriatr Pharmacother. 2008;6:205-211.

SPECIAL OR THEME ISSUE

Clinical Handover: Critical Communications.

Med J Aust. 2009;190:S105-S160.

NEWSPAPER/MAGAZINE ARTICLE

Survive your doctor.

Holt TE. Men's Health. November 3, 2006.

REVIEW

Hospital-initiated transitional care interventions as a patient safety strategy: a systematic review.

Rennke S, Nguyen OK, Shoeb MH, Magan Y, Wachter RM, Ranji SR. Ann Intern Med. 2013;158(5 Pt 2):433-440.

STUDY

Beyond our walls: impact of patient and provider coordination across the continuum on outcomes for surgical patients.

Weinberg DB, Gittell JH, Lusenhop RW, Kautz CM, Wright J. Health Serv Res. 2007;42:7-24.

STUDY

Determinants of patient-reported medication errors: a comparison among seven countries.

Lu CY, Roughead E. Int J Clin Pract. 2011;65:733-740.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing errors relating to commonly used anticoagulants.

Sentinel Event Alert. September 24, 2008;(41):1-4.

COMMENTARY

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

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

COMMENTARY

Assessing hospital safety on nights and weekends: the SWAN tool.

Shulkin DJ. J Patient Saf. 2009;5:75-78.

STUDY

A reengineered hospital discharge program to decrease rehospitalization: a randomized trial.

Jack BW, Chetty VK, Anthony D, et al. Ann Intern Med. 2009;150:178-187.

STUDY

Role of pharmacist counseling in preventing adverse drug events after hospitalization.

Schnipper JL, Kirwin JL, Cotugno MC, et al. Arch Intern Med. 2006;166:565-571.

NEWSPAPER/MAGAZINE ARTICLE

Get me out alive.

Feldman R. The Washington Post. May 2, 2006:HE01.

REVIEW

"July Effect": impact of the academic year-end changeover on patient outcomes. A systematic review.

Young JQ, Ranji SR, Wachter RM, Lee CM, Niehaus B, Auerbach AD. Ann Intern Med. 2011;155:309-315.

MULTI-USE WEBSITE

Safer Sign Out.

Emergency Medicine Patient Safety Foundation.

STUDY

ACGME duty-hour recommendations—a national survey of residency program directors.

Antiel RM, Thompson SM, Reed DA, et al. N Engl J Med. 2010;363:e12.

COMMENTARY

Automated electronic reminders to prevent miscommunication among primary medical, surgical and anaesthesia providers: a root cause analysis.

Freundlich RE, Grondin L, Tremper KK, Saran KA, Kheterpal S. BMJ Qual Saf. 2012;21:850-854.

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