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 (9)

Origin/Sponsor

•Asia (3)

•Australia and New Zealand (14)

Resource Types

•Journal Article (311)

•Legislation/Regulation (3)

•Meeting/Conference (1)

•Newspaper/Magazine Article (29)

•Press Release/Announcement (1)

•Special or Theme Issue (3)

•Tools/Toolkit (9)

•Web Resource (7)

•Grant (4)

Error Types

•Epidemiology of Errors and Adverse Events (65)

•Active Errors (76)

•Latent Errors (56)

•Near Miss (6)

Approach to Improving Safety

•Quality Improvement Strategies (70)

•Legal and Policy Approaches (24)

•Error Reporting and Analysis (43)

•Communication Improvement (277)

•Human Factors Engineering (40)

•Teamwork (35)

•Specialization of Care (27)

•Logistical Approaches (61)

•Culture of Safety (24)

•Technologic Approaches (64)

•Education and Training (101)

Clinical Areas

•Allied Health Services (2)

•Medicine (287)

•Nursing (65)

•Pharmacy (19)

Target Audience

•Health Care Providers (318)

•Health Care Executives and Administrators (280)

•Non-Health Care Professionals (103)

•Patients (17)

Setting of Care

•Hospitals (273)

•Psychiatric Facilities (2)

•Residential Facilities (8)

•Ambulatory Care (41)

•Outpatient Surgery (5)

•Patient Transport (10)

1 - 20 of 380

Show ExcerptDon't Show Excerpt

dropdown

STUDY

Improving handoff communications in critical care: utilizing simulation-based training toward process improvement in managing patient risk.

Berkenstadt H, Haviv Y, Tuval A, et al. Chest. 2008;134:158-162.

STUDY

In search of common ground in handoff documentation in an intensive care unit.

Collins SA, Mamykina L, Jordan D, et al. J Biomed Inform. 2012;45:307-315.

COMMENTARY

DNR in the OR and Afterwards

Lo B. AHRQ WebM&M [serial online]. September 2006.

NEWSPAPER/MAGAZINE ARTICLE

Health IT implementation stories: HANDS care plan tool seeks to improve nurse communication at handoff in AHRQ-funded study.

AHRQ National Resource Center for Health Information Technology.

COMMENTARY

The importance of simulation: preventing hand-off mistakes.

Clancy CM. AORN J. 2008;88:625-627.

GRANT RECIPIENT

Improving Patient Safety Through Simulation Research.

Rockville, MD: Agency for Healthcare Research and Quality; June 2008.

STUDY

Nurses discuss bedside handover and using written handover sheets.

Johnson M, Cowin LS. J Nurs Manag. 2013;21:121-129.

COMMENTARY

On O.R. Off?

Leonard M. AHRQ WebM&M [serial online]. March 2005.

STUDY

Towards an understanding of the information dynamics of the handover process in aged care settings—a prerequisite for the safe and effective use of ICT.

Lyhne S, Georgiou A, Marks A, Tariq A, Westbrook JI. Int J Med Inform. 2012;81:452-460.

STUDY

Why patient summaries in electronic health records do not provide the cognitive support necessary for nurses' handoffs on medical and surgical units: insights from interviews and observations.

Staggers N, Clark L, Blaz JW, Kapsandoy S. Health Informatics J. 2011;17:209-223.

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.

COMMENTARY

Fumbled Handoff.

Vidyarthi A. AHRQ WebM&M [serial online]. March 2004.

COMMENTARY

Discharge Against Medical Advice.

Hwang SW. WebM&M [serial online]. May 2005.

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.

NEWSPAPER/MAGAZINE ARTICLE

Safety in ASCs: putting patients first.

Dix K. Today's Surgicenter. December 1, 2006.

REVIEW

Review: bringing patient safety to the forefront through structured computerisation during clinical handover.

Matic J, Davidson PM, Salamonson Y. J Clin Nurs. 2011;20:184-189.

STUDY

Task uncertainty and communication during nursing shift handovers.

Mayor E, Bangerter A, Aribot M. J Adv Nurs. 2012;68:1956-1966.

NEWSPAPER/MAGAZINE ARTICLE

Do no harm: promoting patient safety.

Ellis K. Surgicenteronline.com [serial online]. May 1, 2006.

REVIEW

Research on nursing handoffs for medical and surgical settings: an integrative review.

Staggers N, Blaz JW. J Adv Nurs. 2013;69:247-262.

STUDY

Safety of telephone triage in general practitioner cooperatives: do triage nurses correctly estimate urgency?

Giesen P, Ferwerda R, Tijssen R, et al. Qual Saf Health Care. 2007;16:181-184.

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