AHRQ Patient Safety Network

The Collection > Communication between Providers

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Safety Target

•Device-related Complications (13)

•Diagnostic Errors (38)

•Identification Errors (34)

•Discontinuities, Gaps, and Hand-Off Problems (281)

•Fatigue and Sleep Deprivation (6)

•Medication Safety (233)

•Medical Complications (51)

•Nonsurgical Procedural Complications (12)

•Surgical Complications (111)

•Transfusion Complications (2)

•Psychological and Social Complications (44)

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•Asia (3)

•Australia and New Zealand (26)

Resource Types

•Journal Article (569)

•Legislation/Regulation (10)

•Meeting/Conference (3)

•Newspaper/Magazine Article (67)

•Special or Theme Issue (16)

•Tools/Toolkit (7)

•Web Resource (12)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (174)

•Active Errors (143)

•Latent Errors (77)

•Near Miss (14)

Approach to Improving Safety
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Communication between Providers

•Read Back Protocols (44)

•Structured Hand-offs (100)

•SBAR (13)

•Medication Reconciliation (130)

Clinical Areas

•Allied Health Services (4)

•Medicine (583)

•Nursing (73)

•Pharmacy (94)

Target Audience

•Health Care Providers (597)

•Health Care Executives and Administrators (591)

•Non-Health Care Professionals (263)

•Patients (21)

Setting of Care

•Hospitals (539)

•Psychiatric Facilities (3)

•Residential Facilities (20)

•Ambulatory Care (78)

•Outpatient Surgery (7)

•Patient Transport (13)

1 - 20 of 720

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STUDY

Professionalism: a necessary ingredient in a culture of safety.

DuPree E, Anderson R, McEvoy MD, Brodman M. Jt Comm J Qual Patient Saf. 2011;37:447-455.

AWARD RECIPIENT

2006 Quest for Quality Prize.

Runy LA. Hosp Health Netw. September 2006.

STUDY

Health care workers as second victims of medical errors.

Edrees HH, Paine LA, Feroli ER, Wu AW. Pol Arch Med Wewn. 2011;121:101-108.

STUDY

Assessing and improving safety culture throughout an academic medical centre: a prospective cohort study.

Paine LA, Rosenstein BJ, Sexton JB, Kent P, Holzmueller CG, Pronovost PJ. Qual Saf Health Care. 2010;19:547-554.

COMMENTARY

Learning accountability for patient outcomes.

Pronovost PJ. JAMA. 2010;304:204-205.

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

Structured interdisciplinary rounds in a medical teaching unit: improving patient safety.

O’Leary KJ, Buck R, Fligiel HM, et al. Arch Intern Med. 2011;171:678-684.

STUDY

Are opioid dependence and methadone maintenance treatment (MMT) documented in the medical record? A patient safety issue.

Walley AY, Farrar D, Cheng DM, Alford DP, Samet JH. J Gen Intern Med. 2009;24:1007-1011.

STUDY

Medication details documented on hospital discharge: cross-sectional observational study of factors associated with medication non-reconciliation.

Grimes TC, Duggan CA, Delaney TP, et al. Br J Clin Pharmacol. 2011;71:449-457.

NEWSPAPER/MAGAZINE ARTICLE

Empowered to improve.

Gardner E. Mod Healthc. May 18, 2009;39:28-31.

STUDY

Rethinking resident supervision to improve safety: from hierarchical to interprofessional models.

Tamuz M, Giardina TD, Thomas EJ, Menon S, Singh H. J Hosp Med. 2011;6:448-456.

NEWSPAPER/MAGAZINE ARTICLE

Raising the index of suspicion: red flags that represent credible threats to patient safety.

ISMP Medication Safety Alert! Acute Care Edition. July 26, 2012;17:1-3.

STUDY

Adequacy of hospital discharge summaries in documenting tests with pending results and outpatient follow-up providers.

Were MC, Li X, Kesterson J, et al. J Gen Intern Med. 2009;24:1002-1006.

STUDY

Potential risk of medication discrepancies and reconciliation errors at admission and discharge from an inpatient medical service.

Climente-Martí M, García-Mañón ER, Artero-Mora AA, Jiménez-Torres NV. Ann Pharmacother. 2010;44:1747-1754.

STUDY

The effect of medication reconciliation in elderly patients at hospital discharge.

Midlöv P, Bahrani L, Seyfali M, Höglund P, Rickhag E, Eriksson T. Int J Clin Pharm. 2012;34:113-119.

BOOK/REPORT

Meeting the Joint Commission's 2013 National Patient Safety Goals.

Oakbrook Terrace, IL: The Joint Commission; September 2012. ISBN: 9781599407555.

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.

STUDY

Association between hospital-reported Leapfrog Safe Practices scores and inpatient mortality.

Kernisan LP, Lee SJ, Boscardin WJ, Landefeld CS, Dudley RA. JAMA. 2009;301:1341-1348.

AUDIOVISUAL

How a simple checklist can dramatically reduce medical errors.

Pronovost PJ. On Call. IHI Open School for Health Professionals. November 3, 2008.

COMMENTARY

Improving heparin safety: a multidisciplinary invited conference.

Peterson C, Ham CW, Vanderveen T. Hosp Pharm. 2008;43:491-497.

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