AHRQ Patient Safety Network

The Collection > Communication between Providers

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Safety Target

•Device-related Complications (18)

•Diagnostic Errors (45)

•Identification Errors (43)

•Discontinuities, Gaps, and Hand-Off Problems (272)

•Fatigue and Sleep Deprivation (6)

•Medication Safety (271)

•Medical Complications (50)

•Nonsurgical Procedural Complications (15)

•Surgical Complications (141)

•Transfusion Complications (2)

•Psychological and Social Complications (39)

Origin/Sponsor

•Asia (6)

•Australia and New Zealand (31)

Resource Types

•Clinical Guideline (1)

•Journal Article (595)

•Legislation/Regulation (10)

•Meeting/Conference (4)

•Newspaper/Magazine Article (69)

•Press Release/Announcement (1)

•Special or Theme Issue (12)

•Tools/Toolkit (9)

•Web Resource (9)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (138)

•Active Errors (190)

•Latent Errors (102)

•Near Miss (18)

Approach to Improving Safety
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Communication between Providers

•Read Back Protocols (66)

•Structured Hand-offs (80)

•SBAR (10)

•Medication Reconciliation (137)

Clinical Areas

•Allied Health Services (4)

•Medicine (587)

•Nursing (81)

•Pharmacy (124)

Target Audience

•Health Care Providers (643)

•Health Care Executives and Administrators (612)

•Non-Health Care Professionals (258)

•Patients (25)

Setting of Care

•Hospitals (536)

•Psychiatric Facilities (3)

•Residential Facilities (23)

•Ambulatory Care (90)

•Outpatient Surgery (8)

•Patient Transport (14)

1 - 20 of 743

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COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:18-21.

NEWSPAPER/MAGAZINE ARTICLE

No more blame & shame: developing event-reporting systems may go a long way to reducing patient care errors in EMS.

Rajasekaran K, Fairbanks RJ, Shah MN. EMS Magazine. September 2008.

NEWSPAPER/MAGAZINE ARTICLE

DTaP–Tdap mix-ups now affecting hundreds of patients.

ISMP Medication Safety Alert! Acute Care Edition. July 1, 2010;15:1-2.

NEWSPAPER/MAGAZINE ARTICLE

Baby's death spotlights safety risks linked to computerized systems.

Graham J, Dizikes C. Chicago Tribune. June 27, 2011.

NEWSPAPER/MAGAZINE ARTICLE

ISMP updates its list of drug name pairs with Tall man letters.

ISMP Medication Safety Alert! Acute Care Edition. November 18, 2010;15:1-3.

NEWSPAPER/MAGAZINE ARTICLE

Misidentification of alphanumeric symbols in both handwritten and computer-generated information.

ISMP Medication Safety Alert! Acute Care Edition. July 2, 2009;14:1-2.

STUDY

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

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

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.

NEWSPAPER/MAGAZINE ARTICLE

Order scanning systems may pull multiple pages through the scanner at the same time, leading to drug omissions.

ISMP Medication Safety Alert! Acute Care Edition. November 5, 2009;14:1-3.

COMMENTARY

Failure to Report

Spath PL. AHRQ WebM&M [serial online]. March 2007.

NEWSPAPER/MAGAZINE ARTICLE

Debriefing for patient safety.

Turner SH, Kurtz WD. Patient Saf Qual Healthc. November/December 2008:5:42-44,46.

COMMENTARY

Improving the safety of intravenous admixtures: lessons learned from a Pentostam® overdose.

Just S, Schepers G, Piotrowski MM, Saint S, Kauffman CA. Jt Comm J Qual Patient Saf. 2006;32:366-372.

STUDY

Analysis of surgical errors in closed malpractice claims at 4 liability insurers.

Rogers SO Jr, Gawande AA, Kwaan M, Puopolo AL, Yoon C, Brennan TA, Studdert DM. Surgery. 2006;140:25-33.

COMMENTARY classic

Fixing healthcare from the inside, today.

Spear SJ. Harv Bus Rev. September 2005;83:78-91.

STUDY

Deconstructing intraoperative communication failures.

Hu YY, Arriaga AF, Peyre SE, Corso KA, Roth EM, Greenberg CC. J Surg Res. 2012;177:37-42.

NEWSPAPER/MAGAZINE ARTICLE

Survey on LASA drug name pairs: who knows what’s on your list and the best ways to prevent mix-ups?

ISMP Medication Safety Alert! Acute Care Edition. May 21, 2009;14:1-3.

COMMENTARY

Eptifibatide Epilogue

Churchill WW, Fiumara K. AHRQ WebM&M [serial online]. April 2009.

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.

COMMENTARY

Sick and Pregnant

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

COMMENTARY

Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery.

Knight N, Aucar J. Am J Surg. 2010;200:803-807.

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