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

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Adverse Events after Hospital Discharge
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Discontinuities, Gaps, and Hand-Off Problems

•Missed or Critical Lab Results (40)

Origin/Sponsor

•Australia and New Zealand (28)

•North America (489)

Resource Types

•Audiovisual (3)

•Book/Report (22)

•Journal Article (515)

•Legislation/Regulation (11)

•Meeting/Conference (2)

•Newspaper/Magazine Article (53)

•Press Release/Announcement (1)

•Special or Theme Issue (12)

•Tools/Toolkit (9)

•Web Resource (13)

Error Types

•Epidemiology of Errors and Adverse Events (150)

•Active Errors (122)

•Latent Errors (74)

•Near Miss (8)

Approach to Improving Safety

•Quality Improvement Strategies (140)

•Legal and Policy Approaches (43)

•Error Reporting and Analysis (104)

•Communication Improvement (439)

•Human Factors Engineering (61)

•Teamwork (51)

•Specialization of Care (53)

•Logistical Approaches (100)

•Culture of Safety (43)

•Technologic Approaches (125)

•Education and Training (142)

Clinical Areas

•Allied Health Services (3)

•Medicine (530)

•Nursing (46)

•Pharmacy (54)

Target Audience

•Health Care Providers (503)

•Health Care Executives and Administrators (509)

•Non-Health Care Professionals (197)

•Patients (41)

Setting of Care

•Hospitals (468)

•Psychiatric Facilities (4)

•Residential Facilities (18)

•Ambulatory Care (109)

•Outpatient Surgery (6)

•Patient Transport (18)

1 - 20 of 645

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STUDY

'Tempos' management in primary care: a key factor for classifying adverse events, and improving quality and safety.

Amalberti R, Brami J. BMJ Qual Saf. 2012;21:729-736.

STUDY

Improving medication reconciliation in the outpatient setting.

Varkey P, Cunningham J, Bisping S. Jt Comm J Qual Patient Saf. 2007;33:286-292.

STUDY

Are opioid dependence and methadone maintenance treatment (MMT) documented in the medical record? A patient safety issue.

Walley AY, Farrar D, Cheng DM, Alford DP, Samet JH. J Gen Intern Med. 2009;24:1007-1011.

REVIEW

Meta-analysis: effect of interactive communication between collaborating primary care physicians and specialists.

Foy R, Hempel S, Rubenstein L, et al. Ann Intern Med. 2010;152:247-258.

COMMENTARY

Reducing diagnostic error through medical home-based primary care reform.

Singh H, Graber M. JAMA. 2010;304:463-464.

AUDIOVISUAL

Healthcare 411: Making hospital discharges safer for seniors.

Rockville, MD: Agency for Healthcare Research and Quality. June 3, 2009.

STUDY

classic

Information exchange among physicians caring for the same patient in the community.

van Walraven C, Taljaard M, Bell CM, et al. CMAJ. 2008;179:1013-1018.

STUDY

Electronic medical record availability and primary care depression treatment.

Harman JS, Rost KM, Harle CA, Cook RL. J Gen Intern Med. 2012;27:962-967.

STUDY

Physician perspectives on quality and error in the outpatient setting.

Manwell LB, Williams ES, Babbott S, Rabatin JS, Linzer M. WMJ. 2009;108:139-144.

STUDY

Early readmissions to the department of medicine as a screening tool for monitoring quality of care problems.

Balla U, Malnick S, Schattner A. Medicine (Baltimore). 2008;87:294-300.

STUDY

Problems after discharge and understanding of communication with their primary care physicians (PCPs) among hospitalized seniors: a mixed methods study.

Arora VM, Prochaska ML, Farnan JM, et al. J Hosp Med. 2010;5:385-391.

STUDY

Trends in primary care clinician perceptions of a new electronic health record.

El-Kareh R, Gandhi TK, Poon EG, et al. J Gen Intern Med. 2009;24:464-468.

BOOK/REPORT

Managing Patients' Medicines after Discharge from Hospital.

London, UK: Care Quality Commission; October 2009. CQC-039-500-ESP-102009. ISBN: 9781845622442.

STUDY

Saving lives by studying deaths: using standardized mortality reviews to improve inpatient safety.

Lau H, Litman KC. Jt Comm J Qual Patient Saf. 2011;37:400-408.

STUDY

Post-discharge medication reviews for patients with heart failure: a pilot study.

Ponniah A, Shakib S, Doecke CJ, Boyce M, Angley M. Pharm World Sci. 2008;30:810-815.

COMMENTARY

Urine a Tough Position.

Gandhi TK. AHRQ WebM&M [serial online]. October 2003.

BOOK/REPORT

Patient Safety in Primary Care.

Kingston-Riechers J, Ospina M, Jonsson E, Childs P, McLeod L, Maxted JM. Edmondton, AB, Canada: Canadian Patient Safety Institute; 2010. ISBN: 9781926541273.

STUDY

Performance of a fail-safe system to follow up abnormal mammograms in primary care.

Grossman E, Phillips RS, Weingart SN. J Patient Saf. 2010;6:172-179.

TOOLKIT

Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation.

Gleason KM, Brake H, Agramonte V, Perfetti C. Rockville, MD: Agency for Healthcare Research and Quality; Revised August 2012. AHRQ Publication No. 11(12)-0059.

STUDY

Creating a better discharge summary: improvement in quality and timeliness using an electronic discharge summary.

O'Leary KJ, Liebovitz SM, Feinglass J, et al. J Hosp Med. 2009;4:219-225.

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