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 (4)

Origin/Sponsor

•Australia and New Zealand (6)

Resource Types

•Journal Article (407)

•Legislation/Regulation (10)

•Newspaper/Magazine Article (68)

•Special or Theme Issue (6)

•Tools/Toolkit (9)

•Web Resource (12)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (132)

•Active Errors (69)

•Latent Errors (43)

•Near Miss (2)

Approach to Improving Safety

•Quality Improvement Strategies (94)

•Legal and Policy Approaches (29)

•Error Reporting and Analysis (73)

•Communication Improvement (361)

•Human Factors Engineering (28)

•Teamwork (39)

•Specialization of Care (52)

•Logistical Approaches (75)

•Culture of Safety (24)

•Technologic Approaches (82)

•Education and Training (119)

Clinical Areas

•Allied Health Services (3)

•Medicine (404)

•Nursing (47)

•Pharmacy (67)

Target Audience

•Health Care Providers (386)

•Health Care Executives and Administrators (387)

•Non-Health Care Professionals (149)

•Patients (48)

Setting of Care

•Hospitals (396)

•Psychiatric Facilities (2)

•Residential Facilities (14)

•Ambulatory Care (73)

•Outpatient Surgery (5)

•Patient Transport (10)

1 - 20 of 534

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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

Challenges faced in providing safe care in rural perinatal settings.

Jukkala AM, Kirby RS. MCN Am J Matern Child Nurs. 2009;34:365-371.

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.

NEWSPAPER/MAGAZINE ARTICLE

Practitioners agree on medication reconciliation value, but frustration and difficulties abound.

ISMP Medication Safety Alert! Acute Care Edition. July 13, 2006;11:1-2.

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.

COMMENTARY

Perinatal patient safety from the perspective of nurse executives: a round table discussion.

Thorman KE, Capitulo KL, Dubow J, Hanold K, Noonan M, Wehmeyer J. J Obstet Gynecol Neonatal Nurs. 2006;35:409-416.

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.

COMMENTARY

Medication reconciliation physician order form.

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

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

An effort to improve electronic health record medication list accuracy between visits: patients' and physicians' response.

Staroselsky M, Volk LA, Tsurikova R, et al. Int J Med Inform. 2008;77:153-160.

STUDY

Predictors of likelihood of speaking up about safety concerns in labour and delivery.

Lyndon A, Sexton JB, Simpson KR, Rosenstein A, Lee KA, Wachter RM. BMJ Qual Saf. 2012;21;791-799.

STUDY

Assessment of a safety enhancement to the hospital medication reconciliation process for elderly patients.

Gizzi LA, Slain D, Hare JT, Sager R, Briggs F 3rd, Palmer CH. Am J Geriatr Pharmacother. 2010;8:127-135.

COMMENTARY

Implementation of a specialized pharmacy team to monitor high-risk medications during discharge.

Martin ES III, Overstreet RL, Jackson-Khalil LR, McCollough HL, Meyer TA, Xu Q. Am J Health Syst Pharm. 2013;70:18-21.

STUDY

Impact of a pharmacist on medication reconciliation on patient admission to a Veterans Affairs Medical Center.

Strunk LB, Matson AW, Steinke D. Hosp Pharm. 2008;43:643-649.

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

Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study.

Walker PC, Bernstein SJ, Tucker Jones JN, et al. Arch Intern Med. 2009;169:2003-2010.

NEWSPAPER/MAGAZINE ARTICLE

Fixing the medication reconciliation breakdown.

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

STUDY

Effects of technological interventions on the safety of a medication-use system.

Skibinski KA, White BA, Lin LI, Dong Y, Wu W. Am J Health Syst Pharm. 2007;64:90-96.

COMMENTARY

The tangible handoff: a team approach for advancing structured communication in labor and delivery.

Block M, Ehrenworth JF, Cuce VM, et al. Jt Comm J Qual Patient Saf. 2010;36:282-287.

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