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 (69)

Origin/Sponsor

•Asia (6)

•Australia and New Zealand (31)

Resource Types

•Journal Article (610)

•Legislation/Regulation (11)

•Meeting/Conference (1)

•Newspaper/Magazine Article (80)

•Special or Theme Issue (13)

•Tools/Toolkit (9)

•Web Resource (16)

•Grant (2)

Error Types

•Epidemiology of Errors and Adverse Events (170)

•Active Errors (136)

•Latent Errors (88)

•Near Miss (7)

Approach to Improving Safety

•Quality Improvement Strategies (154)

•Legal and Policy Approaches (46)

•Error Reporting and Analysis (114)

•Communication Improvement (504)

•Human Factors Engineering (70)

•Teamwork (60)

•Specialization of Care (67)

•Logistical Approaches (143)

•Culture of Safety (39)

•Technologic Approaches (152)

•Education and Training (163)

Clinical Areas

•Allied Health Services (4)

•Medicine (601)

•Nursing (65)

•Pharmacy (71)

Target Audience

•Health Care Providers (564)

•Health Care Executives and Administrators (569)

•Non-Health Care Professionals (228)

•Patients (55)

Setting of Care

•Hospitals (564)

•Psychiatric Facilities (3)

•Residential Facilities (19)

•Ambulatory Care (117)

•Outpatient Surgery (5)

•Patient Transport (16)

1 - 20 of 773

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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.

STUDY

An institution-wide handoff task force to standardise and improve physician handoffs.

Horwitz LI, Schuster KM, Thung SF, et al. BMJ Qual Saf. 2012;21:863-871.

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.

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.

STUDY

Who's covering our loved ones: surprising barriers in the sign-out process.

Antonoff MB, Berdan EA, Kirchner VA, et al. Am J Surg. 2013;205:77-84.

REVIEW

Research on nursing handoffs for medical and surgical settings: an integrative review.

Staggers N, Blaz JW. J Adv Nurs. 2013;69:247-262.

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.

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

Concept and development of a discharge alert filter for abnormal laboratory values coupled with computerized provider order entry: a tool for quality improvement and hospital risk management.

Mathew G, Kho A, Dexter P, et al. J Patient Saf. 2012;8:69-75.

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

Systematically improving physician assignment during in-hospital transitions of care by enhancing a preexisting hospital electronic health record.

Zsenits B, Polashenski WA, Sterns RH, Brown DR IV, Moheet A. J Hosp Med. 2009;4:308-312.

STUDY

Creating a better discharge summary: improvement in quality and timeliness using an electronic discharge summary.

O'Leary KJ, Liebovitz SM, Feinglass J, et al. J Hosp Med. 2009;4:219-225.

COMMENTARY

2009 National Patient Safety Goals.

Saufl NM. J Perianesth Nurs. 2009;24:114-118.

STUDY

Design and implementation of an automated email notification system for results of tests pending at discharge.

Dalal AK, Schnipper JL, Poon EG, et al. J Am Med Inform Assoc. 2012;19:523-538.

STUDY

Design and implementation of an application and associated services to support interdisciplinary medication reconciliation efforts at an integrated healthcare delivery network.

Poon EG, Blumenfeld B, Hamann C, et al. J Am Med Inform Assoc. 2006;13:581-592.

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

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.

NEWSPAPER/MAGAZINE ARTICLE

Safety in numbers? Try connectivity.

Dyell D. Patient Saf Qual Healthc. January/February 2012;9:34-37.

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

Use of an appreciative inquiry approach to improve resident sign-out in an era of multiple shift changes.

Helms AS, Perez TE, Baltz J, et al. J Gen Intern Med. 2012;27:287-291.

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