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 (43)

Origin/Sponsor

•Asia (4)

•Australia and New Zealand (26)

Resource Types

•Journal Article (563)

•Legislation/Regulation (11)

•Meeting/Conference (2)

•Newspaper/Magazine Article (74)

•Special or Theme Issue (15)

•Tools/Toolkit (11)

•Web Resource (17)

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Error Types

•Epidemiology of Errors and Adverse Events (163)

•Active Errors (118)

•Latent Errors (77)

•Near Miss (6)

Approach to Improving Safety

•Quality Improvement Strategies (141)

•Legal and Policy Approaches (50)

•Error Reporting and Analysis (113)

•Communication Improvement (477)

•Human Factors Engineering (62)

•Teamwork (62)

•Specialization of Care (65)

•Logistical Approaches (120)

•Culture of Safety (47)

•Technologic Approaches (131)

•Education and Training (161)

Clinical Areas

•Allied Health Services (5)

•Medicine (552)

•Nursing (66)

•Pharmacy (70)

Target Audience

•Health Care Providers (534)

•Health Care Executives and Administrators (539)

•Non-Health Care Professionals (208)

•Patients (56)

Setting of Care

•Hospitals (532)

•Psychiatric Facilities (3)

•Residential Facilities (21)

•Ambulatory Care (107)

•Outpatient Surgery (5)

•Patient Transport (16)

1 - 20 of 732

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COMMENTARY

Medication reconciliation physician order form.

Lacy JL, Wilkinson ST. Hosp Pharm. 2006;41:1117-1120.

STUDY

Implementation of an electronic system for medication reconciliation.

Kramer JS, Hopkins PJ, Rosendale JC, et al. Am J Health Syst Pharm. 2007;64:404-422.

NEWSPAPER/MAGAZINE ARTICLE

Accuracy at every step: the challenge of medication reconciliation.

Institute for Healthcare Improvement Web site. March 20, 2006.

NEWSPAPER/MAGAZINE ARTICLE

Survey results: community liaison programs to decrease hospital readmissions.

ISMP Medication Safey Alert! Acute Care Edition. March 7, 2013;18:1-3.

STUDY

Medication reconciliation for reducing drug-discrepancy adverse events.

Boockvar KS, Carlson Lacorte H, Giambanco V, Fridman B, Siu A. Am J Geriatr Pharmacother. 2006;4:236-243.

STUDY

"Did I do as best as the system would let me?" Healthcare professional views on hospital to home care transitions.

Davis MM, Devoe M, Kansagara D, Nicolaidis C, Englander H. J Gen Intern Med. 2012;27:1649-1656.

NEWSPAPER/MAGAZINE ARTICLE

JCAHO tightens leash on medication reconciliation.

Perry LE. Drug Topics: Health-System Edition. March 20, 2006.

COMMENTARY

Citrate Mix-Up

Weber RJ. AHRQ WebM&M [serial online]. May 2006.

BOOK/REPORT

Medication Reconciliation Handbook.

Oakbrook Terrace, IL: Joint Commission Resources and the American Society of Health-System Pharmacists; 2006. ISBN: 0866889566.

COMMENTARY

What medications does your patient take? Enhancing medication safety in the outpatient setting.

Institute for Healthcare Improvement. March 14, 2007.

NEWSPAPER/MAGAZINE ARTICLE

Fixing the medication reconciliation breakdown.

Starr D, West L. Most Wired Magazine. November 9, 2006.

COMMENTARY

Improving care transitions: current practice and future opportunities for pharmacists.

American College of Clinical Pharmacy, Hume AL, Kirwin J, et al. Pharmacotherapy. 2012;32:e326-e337.

STUDY

Challenges in posthospital care: nurses as coaches for medication management.

Costa LL, Poe SS, Lee MC. J Nurs Care Qual. 2011;26:243-251.

STUDY

Avoiding handover fumbles: a controlled trial of a structured handover tool versus traditional handover methods.

Payne CE, Stein JM, Leong T, Dressler DD. BMJ Qual Saf. 2012;21:925-932.

STUDY

Effectiveness of a pharmacist–nurse intervention on resolving medication discrepancies for patients transitioning from hospital to home health care.

Setter SM, Corbett CF, Neumiller JJ, Gates BJ, Sclar DA, Sonnett TE. Am J Health Syst Pharm. 2009;66:2027-2031.

COMMENTARY

Patient safety beyond the hospital.

Gandhi TK, Lee TH. N Engl J Med. 2010;363:1001-1003.

ORGANIZATIONAL POLICY/GUIDELINES

Using medication reconciliation to prevent errors.

Sentinel Event Alert. January 25, 2006;(35):1-4.

NEWSPAPER/MAGAZINE ARTICLE

Manic for medication safety: bar codes and drug information databases are helping to reduce medication errors.

Rogoski RR. Health Manage Technol. February 2007;28:14, 16-18.

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.

NEWSPAPER/MAGAZINE ARTICLE

Five hospitals release data on inspections.

Kowalczyk L. Boston Globe. April 21, 2007:B1.

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