AHRQ Patient Safety Network

The Collection > Communication between Providers

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Safety Target

•Device-related Complications (22)

•Diagnostic Errors (51)

•Identification Errors (58)

•Discontinuities, Gaps, and Hand-Off Problems (441)

•Fatigue and Sleep Deprivation (9)

•Medication Safety (346)

•Medical Complications (57)

•Nonsurgical Procedural Complications (15)

•Surgical Complications (180)

•Transfusion Complications (2)

•Psychological and Social Complications (56)

Origin/Sponsor

•Asia (7)

•Australia and New Zealand (43)

Resource Types

•Clinical Guideline (1)

•Journal Article (810)

•Legislation/Regulation (14)

•Meeting/Conference (4)

•Newspaper/Magazine Article (122)

•Press Release/Announcement (1)

•Special or Theme Issue (14)

•Tools/Toolkit (16)

•Web Resource (13)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (193)

•Active Errors (216)

•Latent Errors (100)

•Near Miss (20)

Approach to Improving Safety
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Communication between Providers

•Read Back Protocols (88)

•Structured Hand-offs (177)

•SBAR (24)

•Medication Reconciliation (218)

Clinical Areas

•Allied Health Services (4)

•Medicine (782)

•Nursing (126)

•Pharmacy (159)

Target Audience

•Health Care Providers (827)

•Health Care Executives and Administrators (795)

•Non-Health Care Professionals (339)

•Patients (53)

Setting of Care

•Hospitals (760)

•Psychiatric Facilities (4)

•Residential Facilities (27)

•Ambulatory Care (111)

•Outpatient Surgery (12)

•Patient Transport (17)

1 - 20 of 1045

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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

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.

STUDY

Medication discrepancies upon hospital to skilled nursing facility transitions.

Tjia J, Bonner A, Briesacher BA, McGee S, Terrill E, Miller K. J Gen Intern Med. 2009;24:630-635.

STUDY

Improving situation awareness to reduce unrecognized clinical deterioration and serious safety events.

Brady PW, Muething S, Kotagal U, et al. Pediatrics. 2013;131:e298-e308.

COMMENTARY

ISMP medication error report analysis.

Cohen MR, Smetzer JL. Hosp Pharm. 2009;44:847-853.

COMMENTARY

ISMP medication error report analysis.

Smetzer JL, Cohen MR. Hosp Pharm. 2008;43:869-872.

COMMENTARY

Automated electronic reminders to prevent miscommunication among primary medical, surgical and anaesthesia providers: a root cause analysis.

Freundlich RE, Grondin L, Tremper KK, Saran KA, Kheterpal S. BMJ Qual Saf. 2012;21:850-854.

NEWSPAPER/MAGAZINE ARTICLE

Oops, sorry, wrong patient! A patient verification process is needed everywhere, not just at the bedside.

ISMP Medication Safety Alert! Acute Care Edition. March 10, 2011;16:1-4.

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.

STUDY

Deconstructing intraoperative communication failures.

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

COMMENTARY classic

Fixing healthcare from the inside, today.

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

STUDY

Prescribing discrepancies likely to cause adverse drug events after patient transfer.

Boockvar KS, Liu S, Goldstein N, Nebeker J, Siu A, Fried T. Qual Saf Health Care. 2009;18:32-36.

SPECIAL OR THEME ISSUE

How-to Guides: Improving Transitions from the Hospital to Reduce Avoidable Rehospitalizations.

Cambridge, MA: Institute for Healthcare Improvement; June 2012.

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 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

Effects of an enhanced discharge planning intervention for hospitalized older adults: a randomized trial.

Altfeld SJ, Shier GE, Rooney M, et al. Gerontologist. 2012 Sep 7; [Epub ahead of print].

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.

STUDY

Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care unit.

Joy BF, Elliott E, Hardy C, Sullivan C, Backer CL, Kane JM. Pediatr Crit Care Med. 2011;12:304-308.

STUDY

Effectiveness of a pharmacist–nurse intervention on resolving medication discrepancies for patients transitioning from hospital to home health care.

Setter SM, Corbett CF, Neumiller JJ, Gates BJ, Sclar DA, Sonnett TE. Am J Health Syst Pharm. 2009;66:2027-2031.

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