Development and sustainability of an inpatient-to-outpatient discharge handoff tool: a quality improvement project.

Nicholas Y. Moy; Sei J. Lee; Tyrone Chan; Brittany Grovey; John Boscardin; Ralph Gonzales; Edgar Pierluissi

Study

Development and sustainability of an inpatient-to-outpatient discharge handoff tool: a quality improvement project.

April 30, 2014

Moy NY, Lee SJ, Chan T, et al. Jt Comm J Qual Patient Saf. 2014;40(5):219-227.

View more articles from the same authors.

This quality improvement evaluation found that a structured inpatient-to-outpatient handoff tool in the electronic health record was successfully implemented and improved the timeliness of communication, a key step in preventing postdischarge adverse events.

PubMed citation

Available at

Related Resources From the Same Author(s)

Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study.

November 16, 2022

Support from hospital to home for elders: a randomized trial.

October 15, 2014

Hospitalization-associated disability: "She was probably able to ambulate, but I'm not sure."

November 16, 2011

Discussion of medical errors in morbidity and mortality conferences.

March 6, 2005

Optimizing Pediatric Patient Safety in the Emergency Care Setting.

October 19, 2022

Association of diagnostic stewardship for blood cultures in critically ill children with culture rates, antibiotic use, and patient outcomes: results of the Bright STAR Collaborative.

May 18, 2022

Diagnostic blood loss from phlebotomy and hospital-acquired anemia during acute myocardial infarction.

August 24, 2011

Adverse drug events in U.S. adult ambulatory medical care.

May 25, 2011

Prescription of teratogenic medications in United States ambulatory practices.

January 4, 2006

Variation in quality of urgent health care provided during commercial virtual visits.

April 20, 2016

Description and yield of current quality and safety review in selected US academic emergency departments.

August 30, 2017

Preventability and causes of readmissions in a national cohort of general medicine patients.

May 4, 2016

Shift-to-shift handoff effects on patient safety and outcomes: a systematic review.

November 18, 2015

The impact of coronavirus disease 2019 (COVID-19) on healthcare-associated infections in 2020: a summary of data reported to the National Healthcare Safety Network.

September 22, 2021

Patient Safety Innovations

Pharmacist-led mobile health intervention and transplant medication safety: a randomized controlled clinical trial.

April 7, 2022

Lost information during the handover of critically injured trauma patients: a mixed-methods study.

December 16, 2015

Ethical considerations and patient safety concerns for cancelling non-urgent surgeries during the COVID-19 pandemic: a review.

May 12, 2021

National incidence of medication error in surgical patients before and after Accreditation Council for Graduate Medical Education duty-hour reform.

July 8, 2015

To the point: integrating patient safety education Into the obstetrics and gynecology undergraduate curriculum.

August 17, 2016

Families as partners in hospital error and adverse event surveillance.

March 8, 2017

Evaluation of safety in a radiation oncology setting using failure mode and effects analysis.

July 1, 2009

Value of improving patient safety: health economic considerations for rapid response systems-a rapid review of the literature and expert round table.

May 3, 2023

Patient and caregiver factors in ambulatory incident reports: a mixed-methods analysis.

November 24, 2021

Family Input for Quality and Safety (FIQS): using mobile technology for in-hospital reporting from families and patients.

March 2, 2022

Incidence and trends of sepsis in US hospitals using clinical vs claims data, 2009--2014.

September 27, 2017

The effect of hospitalist discontinuity on adverse events.

March 25, 2015

Noise levels in Johns Hopkins Hospital.

December 21, 2005

Drug-induced hypoglycaemia--new insight into an old problem.

October 25, 2006

National cluster-randomized trial of duty-hour flexibility in surgical training.

February 10, 2016

Development of an emergency department trigger tool using a systematic search and modified Delphi process.

July 13, 2016

Improving the quality of the surgical morbidity and mortality conference: a prospective intervention study.

May 22, 2013

Organisational crisis resource management: leading an academic department of emergency medicine through the COVID-19 pandemic.

October 7, 2020

Evaluating ambulatory practice safety: the PROMISES Project administrators and practice staff surveys.

December 17, 2014

Quality and safety implications of emergency department information systems.

July 17, 2013

Randomized trial of reducing ambulatory malpractice and safety risk: results of the Massachusetts PROMISES Project.

July 19, 2017

Association of the 2011 ACGME resident duty hour reform with postoperative patient outcomes in surgical specialties.

August 12, 2015

Effect of genetic diagnosis on patients with previously undiagnosed disease.

November 7, 2018

Race, ethnicity, and 60-day outcomes after hospitalization with COVID-19.

November 17, 2021

There's no place like home--integrating a pharmacist into the hospital-in-home model.

March 17, 2021

Reporting and disclosing medical errors: pediatricians' attitudes and behaviors.

February 7, 2007

Diagnostic errors in paediatric cardiac intensive care.

February 21, 2018

Discrimination, abuse, harassment, and burnout in surgical residency training.

November 20, 2019

Communication and information deficits in patients discharged to rehabilitation facilities: an evaluation of five acute care hospitals.

October 28, 2009

Surgeon commitment to trauma care decreases missed injuries.

November 28, 2012

Deficits in discharge documentation in patients transferred to rehabilitation facilities on anticoagulation: results of a systemwide evaluation.

August 6, 2008

Patients' and providers' perceptions of the preventability of hospital readmission: a prospective, observational study in four European countries.

July 12, 2017

Comparison of the accuracy of human readers versus machine-learning algorithms for pigmented skin lesion classification: an open, web-based, international, diagnostic study.

June 26, 2019

Association of inappropriate outpatient pediatric antibiotic prescriptions with adverse drug events and health care expenditures.

June 8, 2022

Do professionalism lapses in medical school predict problems in residency and clinical practice?

June 17, 2020

Medical errors in neurosurgery.

December 3, 2014

Pilot implementation of a perioperative protocol to guide operating room-to-intensive care unit patient handoffs.

February 29, 2012

Evaluation of clinical practice guidelines on fall prevention and management for older adults: a systematic review.

January 12, 2022

Misdiagnosis of thoracic aortic emergencies occurs frequently among transfers to aortic referral centers: an analysis of over 3700 patients.

October 12, 2022

Association of communication between hospital-based physicians and primary care providers with patient outcomes.

January 21, 2009

Video capture of clinical care to enhance patient safety.

March 1, 2006

Hospital process compliance and surgical outcomes in Medicare beneficiaries.

October 27, 2010

A multistep approach to improving biopsy site identification in dermatology: physician, staff, and patient roles based on a Delphi consensus.

March 26, 2014

Systems approach to health service design, delivery and improvement: a systematic review and meta-analysis.

February 3, 2021

Potentially harmful medication dispenses after a fall or hip fracture: a mixed methods study of a commonly used quality measure.

March 9, 2022

The Lancet Commission on lessons for the future from the COVID-19 pandemic.

October 12, 2022

Bedside shift-to-shift handoffs: a systematic review of the literature.

August 26, 2015

Association between long-term opioid use in family members and persistent opioid use after surgery among adolescents and young adults.

March 13, 2019

Health care-associated invasive MRSA infections, 2005-2008.

August 18, 2010

Postoperative opioid prescribing and the pain scores on Hospital Consumer Assessment of Healthcare Providers and Systems survey.

June 7, 2017

Association of state opioid duration limits with postoperative opioid prescribing.

January 29, 2020

Effect of reducing interns' weekly work hours on sleep and attentional failures.

March 27, 2005

The effect of computerised decision support alerts tailored to intensive care on the administration of high-risk drug combinations, and their monitoring: a cluster randomised stepped-wedge trial.

February 14, 2024

The potential of Twitter as a data source for patient safety.

January 27, 2016

Meta-analyses of the effects of standardized handoff protocols on patient, provider, and organizational outcomes.

February 22, 2017

Hospital-wide code rates and mortality before and after implementation of a rapid response team.

December 10, 2008

Healing our own: a randomized trial to assess benefits of peer support.

February 2, 2022

Incidence and severity of medication reconciliation discrepancies in trauma patients.

August 16, 2023

Failure to debrief after critical events in anesthesia is associated with failures in communication during the event.

March 20, 2019

Medication reconciliation during internal hospital transfer and impact of computerized prescriber order entry.

December 22, 2010

SBAR M&M: a feasible, reliable, and valid tool to assess the quality of, surgical morbidity and mortality conference presentations.

March 14, 2012

Consumer mobile apps for potential drug–drug interaction check: systematic review and content analysis using the Mobile App Rating Scale (MARS).

April 18, 2018

Race and socioeconomic bias in pediatric cardiac transplantation.

February 8, 2023

Assumptions of quality medicine: the role of uncertainty.

June 14, 2017

Nursing home patient safety culture perceptions among US and immigrant nurses.

January 24, 2018

Nosocomial infection, the Deficit Reduction Act, and incentives for hospitals.

October 8, 2008

Nursing home administrators' opinions of the resident safety culture in nursing homes.

February 7, 2007

Adverse events in infants less than 6 months of age after ambulatory surgery and diagnostic imaging requiring anesthesia.

August 10, 2022

Medication safety events after acute myocardial infarction among veterans treated at VA versus non-VA hospitals.

October 25, 2023

The effect of the electronic transmission of prescriptions on dispensing errors and prescription enhancements made in English community pharmacies: a naturalistic stepped wedge study.

May 14, 2014

Incorrect surgical procedures within and outside of the operating room.

November 25, 2009

Boosting medical diagnostics by pooling independent judgments.

August 17, 2016

Association of the 2011 ACGME resident duty hour reform with general surgery patient outcomes and with resident examination performance.

January 14, 2015

How safe are paediatric emergency departments? A national prospective cohort study.

August 3, 2022

Analysis of the interprofessional clinical learning environment for quality improvement and patient safety from perspectives of interprofessional teams.

March 16, 2022

Association of adverse effects of medical treatment with mortality in the United States: a secondary analysis of the Global Burden of Diseases, Injuries, and Risk Factors study.

January 30, 2019

From HRO to HERO: making health equity a core system capability.

November 24, 2021

Addressing veteran health-related social needs: how Joint Commission standards accelerated integration and expansion of tools and services in the Veterans Health Administration.

December 6, 2023

Missed diagnoses of acute myocardial infarction in the emergency department: variation by patient and facility characteristics.

March 18, 2015

Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based sample.

April 23, 2014

Racial disparities in the frequency of patient safety events: results from the National Medicare Patient Safety Monitoring System.

June 1, 2011

Racial, ethnic, and socioeconomic disparities in estimates of AHRQ patient safety indicators.

April 21, 2005

Declaring uncertainty: using quality improvement methods to change the conversation of diagnosis.

March 17, 2021

The impact of critical event checklists on medical management and teamwork during simulated crises in a surgical daycare facility.

June 28, 2017

Recommendations to improve the usability of drug–drug interaction clinical decision support alerts.

November 25, 2015

Association between handover of anesthesiology care and 1-year mortality among adults undergoing cardiac surgery.

March 2, 2022

Related Resources

Enhancing implementation of the I-PASS handoff tool using a provider handoff task force at a Comprehensive Cancer Center.

April 24, 2024

Estimating the impact on patient safety of enabling the digital transfer of patients' prescription information in the English NHS.

April 17, 2024

Scaling up a diagnostic pause at the ICU-to-ward transition: an exploration of barriers and facilitators to implementation of the ICU-PAUSE handoff tool.

September 27, 2023

Improving emergency medicine clinician awareness of prehospital-administered medications.

August 9, 2023

Patient Safety Innovations

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

July 31, 2023

WebM&M Cases

Critical Echocardiogram Result Lost to Follow-up.

June 14, 2023

Patient Safety Innovations

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

May 31, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Perspective

Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions

November 16, 2022

Interview

In Conversation With... Pascale Carayon, PhD and Nicole Werner, PhD

November 16, 2022

Patient Safety Innovations

Journal Article

Study

Catching those who fall through the cracks: integrating a follow-up process for emergency department patients with incidental radiologic findings.

November 16, 2022

Information concerning ICU patients’ families in the handover—the clinicians’ “game of whispers”: a qualitative study.

October 14, 2020

Implementation and sustainability of a medication reconciliation toolkit: a mixed methods evaluation.

August 5, 2020

WebM&M Cases

When the Indications for Drug Administration Blur

June 24, 2020

Information transfer at hospital discharge: a systematic review.

April 15, 2020

Hidden health IT hazards: a qualitative analysis of clinically meaningful documentation discrepancies at transfer out of the pediatric intensive care unit.

August 28, 2019

Ensuring effective care transition communication: implementation of an electronic medical record-based tool for improved cancer treatment handoffs between clinic and infusion nurses.

August 21, 2019

WebM&M Cases

Updates in the Management of High-Risk Pulmonary Embolism

May 1, 2019

WebM&M Cases

Triaging Interhospital Transfers

February 1, 2019

WebM&M Cases

Adverse Event During Intrahospital Transport

February 1, 2019

Impact of the communication and patient hand-off tool SBAR on patient safety: a systematic review.

November 28, 2018

Defining minimum necessary anticoagulation-related communication at discharge: Consensus of the Care Transitions Task Force of the New York State Anticoagulation Coalition.

November 7, 2018

Identifying what is known about improving operating room to intensive care handovers: a scoping review.

February 28, 2018

A QI initiative: implementing a patient handoff checklist for pediatric hospitalist attendings.

February 8, 2017

WebM&M Cases

Lapse in Antibiotics Leads to Sepsis

October 1, 2016

Association of a web-based handoff tool with rates of medical errors.

August 17, 2016

Reliability of verbal handoff assessment and handoff quality before and after implementation of a resident handoff bundle.

June 22, 2016

Physician transition of care: benefits of I-PASS and an electronic handoff system in a community pediatric residency program.

June 22, 2016

Adverse events and near misses relating to information management in a hospital.

June 22, 2016

WebM&M Cases

Dropping to New Lows

April 1, 2016

See More About The Topic

Hospitals

Health Care Providers

Health Care Executives and Administrators

Hospital Medicine

Discontinuities, Gaps, and Hand-Off Problems

Development and sustainability of an inpatient-to-outpatient discharge handoff tool: a quality improvement project.

Pharmacist-led mobile health intervention and transplant medication safety: a randomized controlled clinical trial.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Catching those who fall through the cracks: integrating a follow-up process for emergency department patients with incidental radiologic findings.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Development and sustainability of an inpatient-to-outpatient discharge handoff tool: a quality improvement project.

Pharmacist-led mobile health intervention and transplant medication safety: a randomized controlled clinical trial.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Catching those who fall through the cracks: integrating a follow-up process for emergency department patients with incidental radiologic findings.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site