PATIENT SAFETY PRIMERS
Handoffs and Signouts
Device-related Complications (3)
Diagnostic Errors (7)
Identification Errors (1)
Discontinuities, Gaps, and Hand-Off Problems (153)
Fatigue and Sleep Deprivation (2)
Medication Safety (17)
Medical Complications (3)
Nonsurgical Procedural Complications (1)
Surgical Complications (21)
Psychological and Social Complications (2)
Australia and New Zealand (6)
North America (121)
Journal Article (137)
Newspaper/Magazine Article (13)
Special or Theme Issue (2)
Web Resource (4)
Epidemiology of Errors and Adverse Events (31)
Active Errors (33)
Latent Errors (24)
Near Miss (1)
Approach to Improving Safety
Health Care Providers (131)
Health Care Executives and Administrators (130)
Non-Health Care Professionals (38)
Setting of Care
Residential Facilities (1)
Ambulatory Care (10)
Outpatient Surgery (1)
Patient Transport (8)
1 - 20
Don't Show Excerpt
Sort by relevance
Sort by significance
Sort by title
Sort by date
Sort by author
A 60-year-old man with delayed care for a renal mass.
Schiff GD. JAMA. 2011;305:1890-1898.
An evaluation of information transfer through the continuum of surgical care: a feasibility study.
Nagpal K, Vats A, Ahmed K, Vincent C, Moorthy K. Ann Surg. 2010;252:402-407.
Handoff checklists improve the reliability of patient handoffs in the operating room and postanesthesia care unit.
Boat AC, Spaeth JP. Paediatr Anaesth. 2013 May 18; [Epub ahead of print].
DNR in the OR and Afterwards
Lo B. AHRQ WebM&M [serial online]. September 2006.
The top 10 list for a safe and effective sign-out.
Kemp CD, Bath JM, Berger J, et al. Arch Surg. 2008;143:1008-1010.
Why patient summaries in electronic health records do not provide the cognitive support necessary for nurses' handoffs on medical and surgical units: insights from interviews and observations.
Staggers N, Clark L, Blaz JW, Kapsandoy S. Health Informatics J. 2011;17:209-223.
Patterns of communication breakdowns resulting in injury to surgical patients.
Greenberg CC, Regenbogen SE, Studdert DM, et al. J Am Coll Surg. 2007;204:533-540.
Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis.
Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Qual Saf Health Care. 2005;14:401-407.
Surgical case listing accuracy: failure analysis at a high-volume academic medical center.
Cima RR, Hale C, Kollengode A, Rogers JC, Cassivi SD, Deschamps C. Arch Surg. 2010;145:641-646.
2009 National Patient Safety Goals.
Saufl NM. J Perianesth Nurs. 2009;24:114-118.
Bridging gaps in handoffs: a continuity of care based approach.
Abraham J, Kannampallil TG, Patel VL. J Biomed Inform. 2012;45:240-254.
Medmarx Data Report: A Chartbook of Medication Error Findings from the Perioperative Settings from 1998-2005.
Rockville, MD: United States Pharmacopeia; 2007.
Standardizing hand-off processes.
Crum Gregory BS. AORN J. 2006;84:1059-1061.
Improving Transitions of Care: Hand-off Communications.
Oakbrook Terrace, IL: Joint Commission Center for Transforming Healthcare; June 2012.
Perioperative Patient 'Hand-Off' Tool Kit.
Association of Perioperative Registered Nurses.
Care Transitions Program.
Aurora, CO: The Division of Health Care Policy and Research, University of Colorado Health Sciences Center.
A hospital races to learn lessons of Ferrari pit stop.
Naik G. Wall Street Journal. November 14, 2006:A1. [reprinted on Post-gazette.com].
Research on nursing handoffs for medical and surgical settings: an integrative review.
Staggers N, Blaz JW. J Adv Nurs. 2013;69:247-262.
Information transfer and communication in surgery: a systematic review.
Nagpal K, Vats A, Lamb B, et al. Ann Surg. 2010;252:225-239.
Use of strategies from high-reliability organisations to the patient hand-off by resident physicians: practical implications.
Philibert I. Qual Saf Health Care. 2009;18:261-266.
Produced for the
Agency for Healthcare Research and Quality
team of editors
University of California, San Francisco
with guidance from a prominent
. The AHRQ PSNet site was designed and implemented by Silverchair.
Contact AHRQ PSNet
Terms & Conditions
Freedom of Information Act
The White House
USA.gov: U.S. Government Official Web Portal
Agency for Healthcare Research and Quality • 540 Gaither Road Rockville, MD 20850 • Telephone: (301) 427-1364