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 (3)

Origin/Sponsor

•Asia (2)

•Australia and New Zealand (19)

Resource Types

•Journal Article (248)

•Legislation/Regulation (4)

•Meeting/Conference (1)

•Newspaper/Magazine Article (25)

•Press Release/Announcement (1)

•Special or Theme Issue (6)

•Tools/Toolkit (8)

•Web Resource (6)

•Grant (4)

Error Types

•Epidemiology of Errors and Adverse Events (43)

•Active Errors (68)

•Latent Errors (47)

•Near Miss (7)

Approach to Improving Safety

•Quality Improvement Strategies (77)

•Legal and Policy Approaches (20)

•Error Reporting and Analysis (42)

•Communication Improvement (254)

•Human Factors Engineering (32)

•Teamwork (61)

•Specialization of Care (22)

•Logistical Approaches (48)

•Culture of Safety (31)

•Technologic Approaches (58)

•Education and Training (80)

Clinical Areas

•Allied Health Services (3)

•Medicine (229)

•Nursing (65)

•Pharmacy (17)

Target Audience

•Health Care Providers (257)

•Health Care Executives and Administrators (242)

•Non-Health Care Professionals (94)

•Patients (17)

Setting of Care

•Hospitals (225)

•Psychiatric Facilities (2)

•Residential Facilities (10)

•Ambulatory Care (48)

•Outpatient Surgery (5)

•Patient Transport (6)

1 - 20 of 317

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STUDY

Discharge rounds in the 80-hour workweek: importance of the trauma nurse practitioner.

Haan JM, Dutton RP, Willis M, Leone S, Kramer ME, Scalea TM. J Trauma. 2007;63:339-343.

MULTI-USE WEBSITE

Simulation Training for Rapid Assessment & Improved Teamwork (STRAIT) Project.

Center for Perioperative Research in Quality, Vanderbilt University.

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.

COMMENTARY

Discharge Against Medical Advice.

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

REVIEW

Coordinating care across diseases, settings, and clinicians: a key role for the generalist in practice.

Stille CJ, Jerant A, Bell D, Meltzer D, Elmore JG. Ann Intern Med. 2005;142:700-708.

COMMENTARY

On O.R. Off?

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

ORGANIZATIONAL POLICY/GUIDELINES

AORN Guidance Statement: Safe Medication Practices in Perioperative Settings Across the Life Span.

AORN J. 2006;84:276-278, 280-283.

STUDY

Observational assessment of surgical teamwork: a feasibility study.

Undre S, Healey AN, Darzi A, Vincent CA. World J Surg. 2006;30:1774-1783.

COMMENTARY

Unreported errors in the intensive care unit: a case study of the way we work.

Henneman EA. Crit Care Nurse. 2007;27:27-34.

COMMENTARY

Another Fall.

Bogardus ST Jr. AHRQ WebM&M [serial online]. April 2003.

STUDY

Using a computerized sign-out system to improve physician–nurse communication.

Sidlow R, Katz-Sidlow RJ. Jt Comm J Qual Patient Saf. 2006;32:32-36.

COMMENTARY

Right? Left? Neither!

Howell EA, Chassin MR. AHRQ WebM&M [serial online]. May 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

Bedside shift report improves patient safety and nurse accountability.

Baker SJ. J Emerg Nurs. 2010;36:355-358.

STUDY

Risky procedures by nurses in hospitals: problems and (contemplated) refusals of orders by physicians, and views of physicians and nurses: a questionnaire survey.

de Bie J, Cuperus-Bosma JM, van der Jagt MAB, Gevers JKM, van der Wal G. Int J Nurs Stud. 2005;42:637-648.

COMMENTARY

Waiting Too Long.

Rosen MA. AHRQ WebM&M [serial online]. November 2003.

COMMENTARY

Deploying med reconciliation.

Williams T, Acton C, Hicks RW. Nurs Manage. 2008;39:54-57.

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.

COMMENTARY

Do Me a Favor.

Williamson A. AHRQ WebM&M [serial online]. May 2004.

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.

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