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 (48)

Origin/Sponsor

•Asia (4)

•Australia and New Zealand (25)

Resource Types

•Journal Article (571)

•Legislation/Regulation (11)

•Meeting/Conference (1)

•Newspaper/Magazine Article (74)

•Special or Theme Issue (15)

•Tools/Toolkit (11)

•Web Resource (16)

•Grant (4)

Error Types

•Epidemiology of Errors and Adverse Events (157)

•Active Errors (127)

•Latent Errors (81)

•Near Miss (9)

Approach to Improving Safety

•Quality Improvement Strategies (147)

•Legal and Policy Approaches (53)

•Error Reporting and Analysis (109)

•Communication Improvement (487)

•Human Factors Engineering (61)

•Teamwork (60)

•Specialization of Care (69)

•Logistical Approaches (131)

•Culture of Safety (50)

•Technologic Approaches (135)

•Education and Training (165)

Clinical Areas

•Allied Health Services (3)

•Medicine (564)

•Nursing (70)

•Pharmacy (67)

Target Audience

•Health Care Providers (535)

•Health Care Executives and Administrators (536)

•Non-Health Care Professionals (223)

•Patients (53)

Setting of Care

•Hospitals (547)

•Psychiatric Facilities (4)

•Residential Facilities (19)

•Ambulatory Care (110)

•Outpatient Surgery (6)

•Patient Transport (13)

1 - 20 of 736

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STUDY

Effects of a multicentre teamwork and communication programme on patient outcomes: results from the Triad for Optimal Patient Safety (TOPS) project.

Auerbach AD, Sehgal NL, Blegen MA, et al. BMJ Qual Saf. 2012;22:118-126.

COMMENTARY

Revisiting duty-hour limits — IOM recommendations for patient safety and resident education.

Iglehart JK. N Engl J Med. 2008;359:2633-2635.

STUDY

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

Gaps in pediatric clinician communication and opportunities for improvement.

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

ORGANIZATIONAL POLICY/GUIDELINES

Preventing errors relating to commonly used anticoagulants.

Sentinel Event Alert. September 24, 2008;(41):1-4.

STUDY

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.

MULTI-USE WEBSITE

Joint Commission Center for Transforming Healthcare.

The Joint Commission.

BOOK/REPORT

Inspiring Ideas and Celebrating Successes: A Guidebook to Leading Patient Safety Practices in Ontario Hospitals.

OHA Patient Safety Support Service. Toronto, Ontario, Canada: Ontario Hospital Association; 2006.

REVIEW

Hospital-initiated transitional care interventions as a patient safety strategy: a systematic review.

Rennke S, Nguyen OK, Shoeb MH, Magan Y, Wachter RM, Ranji SR. Ann Intern Med. 2013;158(5 Pt 2):433-440.

BOOK/REPORT

Improving America's Hospitals: The Joint Commission's Report on Quality and Safety 2008.

Oakbrook Terrace, IL: The Joint Commission; November 2008.

REVIEW

Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care.

Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. JAMA. 2007;297:831-841.

STUDY

"Did I do as best as the system would let me?" Healthcare professional views on hospital to home care transitions.

Davis MM, Devoe M, Kansagara D, Nicolaidis C, Englander H. J Gen Intern Med. 2012;27:1649-1656.

REVIEW

Hospital do-not-resuscitate orders: why they have failed and how to fix them.

Yuen JK, Reid MC, Fetters MD. J Gen Intern Med. 2011;26:791-797.

COMMENTARY

Critical conversations: a call for a nonprocedural "time out."

Sehgal NL, Fox M, Sharpe BA, Vidyarthi AR, Blegen M, Wachter RM. J Hosp Med. 2011;6:157-162.

ORGANIZATIONAL POLICY/GUIDELINES

Health care worker fatigue and patient safety.

Sentinel Event Alert. December 14, 2011;(48):1-4.

STUDY

Effect of a systems intervention on the quality and safety of patient handoffs in an internal medicine residency program.

Graham KL, Marcantonio ER, Huang GC, Yang J, Davis RB, Smith CC. J Gen Intern Med. 2013 Apr 18; [Epub ahead of print].

STUDY

Cost implications of ACGME's 2011 changes to resident duty hours and the training environment.

Nuckols TK, Escarce JJ. J Gen Intern Med. 2012;27:241-249.

COMMENTARY

Moving beyond readmission penalties: creating an ideal process to improve transitional care.

Burke RE, Kripalani S, Vasilevskis EE, Schnipper JL. J Hosp Med. 2013;8:102-109.

COMMENTARY

Building physician work hour regulations from first principles and best evidence.

Volpp KG, Landrigan CP. JAMA. 2008;300:1197-1199.

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.

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