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 (41)

Origin/Sponsor

•Asia (3)

•Australia and New Zealand (23)

Resource Types

•Journal Article (532)

•Legislation/Regulation (10)

•Meeting/Conference (2)

•Newspaper/Magazine Article (73)

•Special or Theme Issue (11)

•Tools/Toolkit (9)

•Web Resource (14)

Error Types

•Epidemiology of Errors and Adverse Events (155)

•Active Errors (102)

•Latent Errors (67)

•Near Miss (6)

Approach to Improving Safety

•Quality Improvement Strategies (131)

•Legal and Policy Approaches (40)

•Error Reporting and Analysis (105)

•Communication Improvement (435)

•Human Factors Engineering (60)

•Teamwork (50)

•Specialization of Care (54)

•Logistical Approaches (113)

•Culture of Safety (32)

•Technologic Approaches (124)

•Education and Training (145)

Clinical Areas

•Allied Health Services (3)

•Medicine (522)

•Nursing (59)

•Pharmacy (57)

Target Audience

•Health Care Providers (495)

•Health Care Executives and Administrators (522)

•Non-Health Care Professionals (194)

•Patients (46)

Setting of Care

•Hospitals (487)

•Psychiatric Facilities (3)

•Residential Facilities (15)

•Ambulatory Care (89)

•Outpatient Surgery (5)

•Patient Transport (14)

1 - 20 of 673

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STUDY

Complying with ACGME resident duty hours restrictions: restructuring the 80-hour workweek to enhance education and patient safety at Texas A&M/Scott & White Memorial Hospital.

Ogden PE, Sibbitt S, Howell M, et al. Acad Med. 2006;81:1026-1031.

STUDY

The impact of the 80-hour resident workweek on surgical residents and attending surgeons.

Hutter MM, Kellogg KC, Ferguson CM, Abbott WM, Warshaw AL. Ann Surg. 2006;243:864-871; discussion 871-875.

NEWSPAPER/MAGAZINE ARTICLE

A case that shook medicine.

Lerner BH. The Washington Post. November 28, 2006:HE01.

STUDY

The multitasking clinician: decision-making and cognitive demand during and after team handoffs in emergency care.

Laxmisan A, Hakimzada F, Sayan OR, et al. Int J Med Inform. 2007;76:801-811.

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.

NEWSPAPER/MAGAZINE ARTICLE

Do no harm: promoting patient safety.

Ellis K. Surgicenteronline.com [serial online]. May 1, 2006.

STUDY

A new professionalism? Surgical residents, duty hours restrictions, and shift transitions.

Coverdill JE, Carbonell AM, Fryer J, et al. Acad Med. 2010;85:S72-S75.

NEWSPAPER/MAGAZINE ARTICLE

Safety in ASCs: putting patients first.

Dix K. Today's Surgicenter. December 1, 2006.

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

The effects of on-duty napping on intern sleep time and fatigue.

Arora V, Dunphy C, Chang VY, Ahmad F, Humphrey HJ, Meltzer D. Ann Intern Med. 2006;144:792-798.

COMMENTARY

The Accreditation Council for Graduate Medical Education resident duty hour new standards: history, changes, and impact on staffing of intensive care units.

Pastores SM, O’Connor MF, Kleinpell RM, et al. Crit Care Med. 2011;39:2540-2549.

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

Risk of medication errors at hospital discharge and barriers to problem resolution.

Enguidanos SM, Brumley RD. Home Health Care Serv Q. 2005;24:123-135.

REVIEW

Effects of reducing or eliminating resident work shifts over 16 hours: a systematic review.

Levine AC, Adusumilli J, Landrigan CP. Sleep. 2010;33:1043-1053.

BOOK/REPORT

Improving America's Hospitals: A Report on Quality and Safety.

Oakbrook Terrace, IL: The Joint Commission; March 2007.

STUDY

Predictors of likelihood of speaking up about safety concerns in labour and delivery.

Lyndon A, Sexton JB, Simpson KR, Rosenstein A, Lee KA, Wachter RM. BMJ Qual Saf. 2012;21;791-799.

STUDY

ED handoffs: observed practices and communication errors.

Maughan BC, Lei L, Cydulka RK. Am J Emerg Med. 2011;29:502-511.

STUDY

The hospital discharge: a review of a high risk care transition with highlights of a reengineered discharge process.

Greenwald JL, Denham CR, Jack BW. J Patient Saf. 2007;3:97-106.

STUDY

Bridging gaps in handoffs: a continuity of care based approach.

Abraham J, Kannampallil TG, Patel VL. J Biomed Inform. 2012;45:240-254.

COMMENTARY

An elusive balance — residents' work hours and the continuity of care.

Okie S. N Engl J Med. 2007;356:2665-2667.

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