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The Collection > Discontinuities, Gaps, and Hand-Off Problems

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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

•Australia and New Zealand (25)

•North America (533)

Resource Types

•Audiovisual (6)

•Book/Report (23)

•Journal Article (537)

•Legislation/Regulation (7)

•Meeting/Conference (1)

•Newspaper/Magazine Article (64)

•Press Release/Announcement (1)

•Special or Theme Issue (11)

•Tools/Toolkit (11)

•Web Resource (12)

Error Types

•Epidemiology of Errors and Adverse Events (183)

•Active Errors (121)

•Latent Errors (84)

•Near Miss (8)

Approach to Improving Safety

•Quality Improvement Strategies (138)

•Legal and Policy Approaches (50)

•Error Reporting and Analysis (112)

•Communication Improvement (441)

•Human Factors Engineering (55)

•Teamwork (52)

•Specialization of Care (61)

•Logistical Approaches (114)

•Culture of Safety (39)

•Technologic Approaches (122)

•Education and Training (159)

Clinical Areas

•Allied Health Services (5)

•Medicine (534)

•Nursing (55)

•Pharmacy (63)

Target Audience

•Health Care Providers (497)

•Health Care Executives and Administrators (489)

•Non-Health Care Professionals (200)

•Patients (53)

Setting of Care

•Hospitals (514)

•Psychiatric Facilities (3)

•Residential Facilities (17)

•Ambulatory Care (111)

•Outpatient Surgery (7)

•Patient Transport (10)

1 - 20 of 678

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STUDY

What do patients think about year-end resident continuity clinic handoffs?: a qualitative study.

Pincavage AT, Lee WW, Beiting KJ, Arora VM. J Gen Intern Med. 2013 Apr 18; [Epub ahead of print].

STUDY

Introduction of discharge plan to reduce adverse events within 72 hours of discharge from the ICU.

Williams TA, Leslie GD, Elliott N, Brearley L, Dobb GJ. J Nurs Care Qual. 2010;25:73-79.

STUDY

classic

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

classic

The care transitions intervention: translating from efficacy to effectiveness.

Voss R, Gardner R, Baier R, Butterfield K, Lehrman S, Gravenstein S. Arch Intern Med. 2011;171:1232-1237.

STUDY

Health information technology and its effects on hospital costs, outcomes, and patient safety.

Encinosa WE, Bae J. Inquiry. Winter 2011/2012;48:288-303.

MULTI-USE WEBSITE

Project Red (Re-Engineered Discharge).

Boston, MA: Boston University Medical Center.

STUDY

Use of an appreciative inquiry approach to improve resident sign-out in an era of multiple shift changes.

Helms AS, Perez TE, Baltz J, et al. J Gen Intern Med. 2012;27:287-291.

COMMENTARY

Reengineering hospital discharge: a protocol to improve patient safety, reduce costs, and boost patient satisfaction.

Clancy CM. Am J Med Qual. 2009;24:344-346.

STUDY

classic

Consequences of inadequate sign-out for patient care.

Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. Arch Intern Med. 2008;168:1755-1760.

STUDY

A reengineered hospital discharge program to decrease rehospitalization: a randomized trial.

Jack BW, Chetty VK, Anthony D, et al. Ann Intern Med. 2009;150:178-187.

STUDY

Language barriers and understanding of hospital discharge instructions.

Karliner LS, Auerbach A, Nápoles A, Schillinger D, Nickleach D, Pérez-Stable EJ. Med Care. 2012;50:283-289.

STUDY

Hospital discharge documentation and risk of rehospitalisation.

Hansen LO, Strater A, Smith L, et al. BMJ Qual Saf. 2011;20:773-778.

STUDY

Design and implementation of an automated email notification system for results of tests pending at discharge.

Dalal AK, Schnipper JL, Poon EG, et al. J Am Med Inform Assoc. 2012;19:523-538.

TOOLKIT

Re-Engineered Discharge (RED) Toolkit.

Jack B, Paasche-Orlow M, Mitchell S, Forsythe S, Martin J. Rockville, MD: Agency for Healthcare Research and Quality; March 2013. AHRQ Publication No. 12(13)-0084.

STUDY

Gaps in pediatric clinician communication and opportunities for improvement.

Woods DM, Holl JL, Angst DB, et al. J Healthc Qual. 2008;30:43-54.

STUDY

Characterising physician listening behaviour during hospitalist handoffs using the HEAR checklist.

Greenstein EA, Arora VM, Staisiunas PG, Banerjee SS, Farnan JM. BMJ Qual Saf. 2013;22:219-224.

MULTI-USE WEBSITE

Getting Safer Care.

Agency for Healthcare Research and Quality.

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.

STUDY

Implementing peer evaluation of handoffs: associations with experience and workload.

Arora VM, Greenstein EA, Woodruff JN, Staisiunas PG, Farnan JM. J Hosp Med. 2013;8:132-136.

STUDY

Improving the discharge process by embedding a discharge facilitator in a resident team.

Finn KM, Heffner R, Chang Y, et al. J Hosp Med. 2011;6:494-500.

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