AHRQ Patient Safety Network

The Collection > Communication between Providers

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Safety Target

•Device-related Complications (19)

•Diagnostic Errors (49)

•Identification Errors (60)

•Discontinuities, Gaps, and Hand-Off Problems (348)

•Fatigue and Sleep Deprivation (8)

•Medication Safety (312)

•Medical Complications (56)

•Nonsurgical Procedural Complications (15)

•Surgical Complications (177)

•Transfusion Complications (2)

•Psychological and Social Complications (52)

Origin/Sponsor

•Asia (4)

•Australia and New Zealand (32)

Resource Types

•Clinical Guideline (1)

•Journal Article (739)

•Legislation/Regulation (13)

•Meeting/Conference (4)

•Newspaper/Magazine Article (108)

•Press Release/Announcement (1)

•Special or Theme Issue (14)

•Tools/Toolkit (10)

•Web Resource (11)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (195)

•Active Errors (207)

•Latent Errors (91)

•Near Miss (21)

Approach to Improving Safety
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Communication between Providers

•Read Back Protocols (83)

•Structured Hand-offs (123)

•SBAR (20)

•Medication Reconciliation (180)

Clinical Areas

•Allied Health Services (4)

•Medicine (726)

•Nursing (106)

•Pharmacy (140)

Target Audience

•Health Care Providers (764)

•Health Care Executives and Administrators (730)

•Non-Health Care Professionals (321)

•Patients (47)

Setting of Care

•Hospitals (683)

•Psychiatric Facilities (3)

•Residential Facilities (24)

•Ambulatory Care (102)

•Outpatient Surgery (10)

•Patient Transport (15)

1 - 20 of 938

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STUDY

Interruptions in a level one trauma center: a case study.

Brixey JJ, Tang Z, Robinson DJ, et al. Int J Med Inform. 2008;77:235-241.

COMMENTARY

Recurrent Hypoglycemia: A Care Transition Failure?

Eytan T. AHRQ WebM&M [serial online]. October 2008.

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

Monitoring for medication errors in outpatient settings.

Balkrishnan R, Foss CE, Pawaskar M, Uhas AA, Feldman SR. J Dermatolog Treat. 2009;20:229-232.

STUDY

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

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

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

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

Utilising improvement science methods to optimise medication reconciliation.

White CM, Schoettker PJ, Conway PH, et al. BMJ Qual Saf. 2011;20:372-380.

STUDY

Incidence and impact of physician and nurse disruptive behaviors in the emergency department.

Rosenstein AH, Naylor B. J Emerg Med. 2012;43:139-148.

STUDY

Developing a programme for medication reconciliation at the time of admission into hospital.

Manzorro AG, Zoni AC, Rieiro CR, et al. Int J Clin Pharm. 2011;33:603-609.

COMMENTARY

Sick and Pregnant

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

ORGANIZATIONAL POLICY/GUIDELINES

Safe Site Invasive Procedure—Non-Operating Room.

Bloomington, MN: Institute for Clinical Systems Improvement; 2010.

STUDY

Bringing patients' own medications into an emergency department by ambulance: effect on prescribing accuracy when these patients are admitted to hospital.

Chan EW, Taylor SE, Marriott JL, Barger B. Med J Aust. 2009;191:374-377.

COMMENTARY

ISMP medication error report analysis.

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

BOOK/REPORT

Coordination Between Emergency and Primary Care Physicians.

Carrier E, Yee T, Holtzwart RA. Washington, DC: National Institute for Health Care Reform; 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.

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.

STUDY

Information loss in emergency medical services handover of trauma patients.

Carter AJE, Davis KA, Evans LV, Cone DC. Prehosp Emerg Care. 2009;13:280-285.

STUDY

Beam me up Scotty! Impact of personal wireless communication devices in the emergency department.

Richards JD, Harris T. Emerg Med J. 2011;28:29-32.

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.

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