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 (27)

Origin/Sponsor

•Africa (1)

•Asia (4)

•Australia and New Zealand (21)

Resource Types

•Journal Article (435)

•Legislation/Regulation (6)

•Newspaper/Magazine Article (30)

•Press Release/Announcement (1)

•Special or Theme Issue (7)

•Tools/Toolkit (6)

•Web Resource (6)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (130)

•Active Errors (106)

•Latent Errors (67)

•Near Miss (8)

Approach to Improving Safety

•Quality Improvement Strategies (114)

•Legal and Policy Approaches (25)

•Error Reporting and Analysis (97)

•Communication Improvement (337)

•Human Factors Engineering (54)

•Teamwork (38)

•Specialization of Care (36)

•Logistical Approaches (85)

•Culture of Safety (30)

•Technologic Approaches (94)

•Education and Training (109)

Clinical Areas

•Allied Health Services (2)

•Medicine (415)

•Nursing (46)

•Pharmacy (36)

Target Audience

•Health Care Providers (403)

•Health Care Executives and Administrators (421)

•Non-Health Care Professionals (150)

•Patients (15)

Setting of Care

•Hospitals (372)

•Psychiatric Facilities (2)

•Residential Facilities (11)

•Ambulatory Care (69)

•Outpatient Surgery (5)

•Patient Transport (15)

1 - 20 of 507

Show ExcerptDon't Show Excerpt

dropdown

STUDY

Healthcare provider complaints to the emergency department: a preliminary report on a new quality improvement instrument.

Griffey RT, Bohan JS. Qual Saf Health Care. 2006;15:344-346.

COMMENTARY

Right? Left? Neither!

Howell EA, Chassin MR. AHRQ WebM&M [serial online]. May 2006.

STUDY

Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers.

Kachalia A, Gandhi TK, Puopolo AL, et al. Ann Emerg Med. Ann Emerg Med. 2007;49:196-205.

REVIEW

Missed breast cancers at US-guided core needle biopsy: how to reduce them.

Youk JH, Kim EK, Kim MJ, Lee JY, Oh KK. Radiographics. 2007;27:79-94.

COMMENTARY classic

Graduate medical education and patient safety: a busy--and occasionally hazardous--intersection.

Shojania KG, Fletcher KE, Saint S. Ann Intern Med. 2006;145:592-598.

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.

COMMENTARY

Physical Diagnosis: A Lost Art?

Thompson GR, Verghese A. AHRQ WebM&M [serial online]. August 2006.

STUDY

ED handoffs: observed practices and communication errors.

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

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.

SPECIAL OR THEME ISSUE

Safety in EMS.

Brice JH, Patterson PD, eds. Prehosp Emerg Care. 2012;16:1-108.

STUDY

Pediatric rapid response teams in the academic medical center.

Mistry KP, Turi J, Hueckel R, Mericle JM, Meliones JN. Clin Ped Emerg Med. 2006;7:241-247.

STUDY

A randomized, controlled trial evaluating the impact of a computerized rounding and sign-out system on continuity of care and resident work hours.

Van Eaton EG, Horvath KD, Lober WB, Rossini AJ, Pellegrini CA. J Am Coll Surg. 2005;200:538-545.

STUDY

Waiting for urgent procedures on the weekend among emergently hospitalized patients.

Bell CM, Redelmeier DA. Am J Med. 2004;117:175-181.

STUDY

Discontinuity of chronic medications in patients discharged from the intensive care unit.

Bell CM, Rahimi-Darabad P, Orner AI. J Gen Intern Med. 2006;21:937-941.

STUDY

Design and trial of a new ambulance-to-emergency department handover protocol: 'IMIST-AMBO.'

Iedema R, Ball C, Daly B, et al. BMJ Qual Saf. 2012;21:627-633.

NEWSPAPER/MAGAZINE ARTICLE

Error rate greatest in hospital radiology.

Stein R. The Washington Post. January 18, 2006:A03.

TOOLKIT

Communicating Critical Test Results.

Burlington, MA: Massachusetts Coalition for the Prevention of Medical Errors; 2003.

STUDY

Registration-associated patient misidentification in an academic medical center: causes and corrections.

Bittle MJ, Charache P, Wassilchalk DM. Jt Comm J Qual Patient Saf. 2007;33:25-33.

STUDY

Medical errors arising from outsourcing laboratory and radiology services.

Chasin BS, Elliott SP, Klotz SA. Am J Med. 2007;120:819.e9-11.

NEWSPAPER/MAGAZINE ARTICLE

Ding-a-ling-a-ling: ambulances can be dangerous places.

Meisel Z. Slate. November 8, 2005.

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