AHRQ Patient Safety Network

The Collection > Communication between Providers

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Safety Target

•Device-related Complications (18)

•Diagnostic Errors (40)

•Identification Errors (41)

•Discontinuities, Gaps, and Hand-Off Problems (320)

•Fatigue and Sleep Deprivation (8)

•Medication Safety (245)

•Medical Complications (53)

•Nonsurgical Procedural Complications (15)

•Surgical Complications (146)

•Transfusion Complications (2)

•Psychological and Social Complications (45)

Origin/Sponsor

•Asia (5)

•Australia and New Zealand (34)

Resource Types

•Clinical Guideline (1)

•Journal Article (647)

•Legislation/Regulation (12)

•Meeting/Conference (4)

•Newspaper/Magazine Article (70)

•Press Release/Announcement (1)

•Special or Theme Issue (10)

•Tools/Toolkit (10)

•Web Resource (11)

Error Types

•Epidemiology of Errors and Adverse Events (179)

•Active Errors (190)

•Latent Errors (88)

•Near Miss (16)

Approach to Improving Safety
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Communication between Providers

•Read Back Protocols (58)

•Structured Hand-offs (117)

•SBAR (14)

•Medication Reconciliation (134)

Clinical Areas

•Allied Health Services (4)

•Medicine (632)

•Nursing (90)

•Pharmacy (103)

Target Audience

•Health Care Providers (664)

•Health Care Executives and Administrators (661)

•Non-Health Care Professionals (278)

•Patients (25)

Setting of Care

•Hospitals (622)

•Psychiatric Facilities (3)

•Residential Facilities (21)

•Ambulatory Care (79)

•Outpatient Surgery (9)

•Patient Transport (14)

1 - 20 of 801

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STUDY

Determinants of patient-reported medication errors: a comparison among seven countries.

Lu CY, Roughead E. Int J Clin Pract. 2011;65:733-740.

BOOK/REPORT

An In Depth Investigation into Causes of Prescribing Errors by Foundation Trainees in Relation to Their Medical Education—EQUIP Study.

Dornan T, Ashcroft D, Heathfield H, et al. London: General Medical Council; 2009.

STUDY

An exploratory study measuring verbal order content and context.

Wakefield DS, Brokel J, Ward MM, Schwichtenberg T, Groath D, Kolb M, Davis JW, Crandall D. Qual Saf Health Care. 2009;18:169-173.

REVIEW

An international review of patient safety measures in radiotherapy practice.

Shafiq J, Barton M, Noble D, Lemer C, Donaldson LJ. Radiother Oncol. 2009;92:15-21.

BOOK/REPORT

Breast Cancer Services in Trafford and North Manchester. An Investigation Into The Circumstances Surrounding A Serious Clinical Incident In Symptomatic Breast Services – The Baker Report.

Baker M. Manchester, England: NHS North West; February 2007.

COMMENTARY

Is the Admission Drug Dose Too Low?

Kaushal R, Abramson E. AHRQ WebM&M [serial online]. August 2009.

STUDY

National study on the frequency, types, causes, and consequences of voluntarily reported emergency department medication errors.

Pham JC, Story JL, Hicks RW, et al. J Emerg Med. 2011;40:485-492.

BOOK/REPORT

External Inquiry into the adverse incident that occurred at Queen's Medical Centre, Nottingham, 4th January 2001.

Toft B. London, England: Department of Health; 2001.

STUDY

Use of the WHO surgical safety checklist in trauma and orthopaedic patients.

Sewell M, Adebibe M, Jayakumar P, et al. Int Orthop. 2011;35:897-901.

REVIEW

Improving safety in the operating room: a systematic literature review of retained surgical sponges.

Wan W, Le T, Riskin L, Macario A. Curr Opin Anaesthesiol. 2009;22:207-214.

REVIEW

A systematic review of failures in handoff communication during intrahospital transfers.

Ong MS, Coiera E. Jt Comm J Qual Patient Saf. 2011;37:274-284.

COMMENTARY

Sick and Pregnant

El-Ibiary S. AHRQ WebM&M [serial online]. November 2008.

STUDY

Patient record review of the incidence, consequences, and causes of diagnostic adverse events.

Zwaan L, de Bruijne M, Wagner C, et al. Arch Intern Med. 2010;170:1015-1021.

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.

STUDY

Relationship between systems-level factors and hand hygiene adherence.

Dunn-Navarra AM, Cohen B, Stone PW, Pogorzelska M, Jordan S, Larson E. J Nurs Care Qual. 2011;26:30-38.

STUDY

Stakeholder perspectives on handovers between hospital staff and general practitioners: an evaluation through the microsystems lens.

Göbel B, Zwart D, Hesselink G, Pijnenborg L, Barach P, Kalkman C, Johnson JK. BMJ Qual Saf. 2012;21:i106-i113.

REVIEW

Interventions to improve teamwork and communications among healthcare staff.

McCulloch P, Rathbone J, Catchpole K. Br J Surg. 2011;98:469-479.

BOOK/REPORT classic

The Silent Treatment: Why Safety Tools and Checklists Aren't Enough to Save Lives.

Maxfield D, Grenny J, Lavandero R, Groah L. Provo, UT: VitalSmarts; 2011.

STUDY

Medicines reconciliation using a shared electronic health care record.

Moore P, Armitage G, Wright J, Dobrzanski S, Ansari N, Hammond I, Scally A. J Patient Saf. 2011;7:147-153.

STUDY

The introduction of a surgical safety checklist in a tertiary referral obstetric centre.

Kearns RJ, Uppal V, Bonner J, Robertson J, Daniel M, McGrady EM. BMJ Qual Saf. 2011;20:818-822.

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