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 (44)

Origin/Sponsor

•Africa (1)

•Asia (4)

•Australia and New Zealand (21)

Resource Types

•Journal Article (558)

•Legislation/Regulation (11)

•Newspaper/Magazine Article (69)

•Special or Theme Issue (13)

•Tools/Toolkit (7)

•Web Resource (15)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (187)

•Active Errors (113)

•Latent Errors (76)

•Near Miss (5)

Approach to Improving Safety

•Quality Improvement Strategies (130)

•Legal and Policy Approaches (41)

•Error Reporting and Analysis (114)

•Communication Improvement (445)

•Human Factors Engineering (52)

•Teamwork (54)

•Specialization of Care (62)

•Logistical Approaches (112)

•Culture of Safety (34)

•Technologic Approaches (122)

•Education and Training (160)

Clinical Areas

•Allied Health Services (4)

•Medicine (544)

•Nursing (60)

•Pharmacy (65)

Target Audience

•Health Care Providers (507)

•Health Care Executives and Administrators (506)

•Non-Health Care Professionals (193)

•Patients (52)

Setting of Care

•Hospitals (532)

•Psychiatric Facilities (3)

•Residential Facilities (17)

•Ambulatory Care (93)

•Outpatient Surgery (5)

•Patient Transport (13)

1 - 20 of 702

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STUDY

Changes in hospital mortality associated with residency work-hour regulations.

Shetty KD, Bhattacharya J. Ann Intern Med. 2007;147:73-80.

COMMENTARY

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

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

STUDY

Association of workload of on-call medical interns with on-call sleep duration, shift duration, and participation in educational activities.

Arora VM, Georgitis E, Siddique J, et al. JAMA. 2008;300:1146-1153.

COMMENTARY classic

The new recommendations on duty hours from the ACGME Task Force.

Nasca TJ, Day SH, Amis ES Jr; for ACGME Duty Hours Task Force. N Engl J Med. 2010;363:e3.

COMMENTARY

The response of the APPD, CoPS and AAP to the Institute of Medicine report on resident duty hours.

Guralnick S, Rushton J, Bale JF Jr, Norwood V, Trimm F, Schumacher D. Pediatrics. 2010;125:786-790.

COMMENTARY

The ACGME’s final duty-hour standards—special PGY-1 limits and strategic napping.

Iglehart JK. N Engl J Med. 2010;363:1589-1591.

STUDY

Faculty member review and feedback using a sign-out checklist: improving intern written sign-out.

Bump GM, Bost JE, Buranosky R, Elnicki M. Acad Med. 2012;87;1125-1131.

REVIEW

Impact of reduction in working hours for doctors in training on postgraduate medical education and patients' outcomes: systematic review.

Moonesinghe SR, Lowery J, Shahi N, Millen A, Beard JD. BMJ. 2011;342:d1580.

REVIEW

Myths and realities of the 80-hour work week.

Schenarts PJ, Anderson Schenarts KD, Rotondo MF. Curr Surg. 2006;63:269-274.

STUDY

Residents' perspectives on ACGME regulation of supervision and duty hours—a national survey.

Drolet BC, Spalluto LB, Fischer SA. N Engl J Med. 2010;363:e34.

COMMENTARY

Putting the sleepy resident issue to bed: federal legislation is not the answer to excessive medical resident working hours.

Stone JD. Suffolk Univ Law Rev. 2007;40:745-767.

STUDY

Cost implications of ACGME's 2011 changes to resident duty hours and the training environment.

Nuckols TK, Escarce JJ. J Gen Intern Med. 2012;27:241-249.

COMMENTARY

Revisiting duty-hour limits — IOM recommendations for patient safety and resident education.

Iglehart JK. N Engl J Med. 2008;359:2633-2635.

STUDY

ACGME duty-hour recommendations—a national survey of residency program directors.

Antiel RM, Thompson SM, Reed DA, et al. N Engl J Med. 2010;363:e12.

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.

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.

MULTI-USE WEBSITE

Quality Care and Excellence in Medical Education.

Accreditation Council for Graduate Medical Education.

STUDY

Impact of duty hours restrictions on quality of care and clinical outcomes.

Bhavsar J, Montgomery D, Li J, et al. Am J Med. 2007;120:968-974.

STUDY

Integration of a formalized handoff system into the surgical curriculum: resident perspectives and early results.

Telem DA, Buch KE, Ellis S, Coakley B, Divino CM. Arch Surg. 2011;146:89-93.

STUDY

Medication discrepancies in resident sign-outs and their potential to harm.

Arora V, Kao J, Lovinger D, Seiden SC, Meltzer D. J Gen Intern Med. 2007;22:1751-1755.

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