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 (38)

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•Africa (1)

•Asia (3)

•Australia and New Zealand (32)

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•Journal Article (590)

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•Newspaper/Magazine Article (77)

•Special or Theme Issue (13)

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•Epidemiology of Errors and Adverse Events (164)

•Active Errors (131)

•Latent Errors (89)

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Approach to Improving Safety

•Quality Improvement Strategies (151)

•Legal and Policy Approaches (48)

•Error Reporting and Analysis (115)

•Communication Improvement (503)

•Human Factors Engineering (70)

•Teamwork (66)

•Specialization of Care (65)

•Logistical Approaches (122)

•Culture of Safety (49)

•Technologic Approaches (131)

•Education and Training (165)

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•Allied Health Services (3)

•Medicine (589)

•Nursing (65)

•Pharmacy (63)

Target Audience

•Health Care Providers (559)

•Health Care Executives and Administrators (566)

•Non-Health Care Professionals (223)

•Patients (50)

Setting of Care

•Hospitals (551)

•Psychiatric Facilities (4)

•Residential Facilities (21)

•Ambulatory Care (106)

•Outpatient Surgery (6)

•Patient Transport (20)

1 - 20 of 751

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NEWSPAPER/MAGAZINE ARTICLE

A hospital races to learn lessons of Ferrari pit stop.

Naik G. Wall Street Journal. November 14, 2006:A1. [reprinted on Post-gazette.com].

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.

STUDY

Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality.

Catchpole KR, de Leval MR, McEwan A, et al. Paediatr Anaesth. 2007;17:470-478.

STUDY

Burns surgery handover study: trainees' assessment of current practice in the British Isles.

Al-Benna S, Al-Ajam Y, Alzoubaidi D. Burns. 2009;35:509-512.

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.

COMMENTARY

Handovers from the OR to the ICU.

Bonifacio AS, Segall N, Barbeito A, Taekman J, Schroeder R, Mark JB. Int Anesthesiol Clin. 2013;51:43-61.

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

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

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

STUDY

Handover after pediatric heart surgery: a simple tool improves information exchange.

Zavalkoff SR, Razack SI, Lavoie J, Dancea AB. Pediatr Crit Care Med. 2011;12:309-313.

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

Surgical team behaviors and patient outcomes.

Mazzocco K, Petitti DB, Fong KT, et al. Am J Surg. 2009;197:678-685.

STUDY

The value of adding a verbal report to written handoffs on early readmission following prolonged respiratory failure.

Hess DR, Tokarczyk A, O’Malley M, Gavaghan S, Sullivan J, Schmidt U. Chest. 2010;138:1475-1479.

STUDY

Surgical case listing accuracy: failure analysis at a high-volume academic medical center.

Cima RR, Hale C, Kollengode A, Rogers JC, Cassivi SD, Deschamps C. Arch Surg. 2010;145:641-646.

COMMENTARY

On the Other Hand

Henneman EA. AHRQ WebM&M [serial online]. May 2007.

STUDY

Unplanned transfers to a medical intensive care unit: causes and relationship to preventable errors in care.

Bapoje SR, Gaudiani JL, Narayanan V, Albert RK. J Hosp Med. 2011;6:68-72.

STUDY

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

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

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.

STUDY

Inappropriate medications in elderly ICU survivors: where to intervene?

Morandi A, Vasilevskis EE, Pandharipande PP, et al. Arch Intern Med. 2011;171:1032-1034.

STUDY

Building collaborative teams in neonatal intensive care.

Brodsky D, Gupta M, Quinn M, et al. BMJ Qual Saf. 2013;374-382.

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