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Fumbled Handoff.
Vidyarthi A. AHRQ WebM&M [serial online]. March 2004.
Due to a series of incomplete signouts, information about a patient’s postoperative leg pain and chest discomfort is not conveyed to the primary team. A pulmonary embolism is discovered postmortem
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Resource Type
Commentary
Setting of Care
Hospitals
Target Audience
Health Care Providers
Quality and Safety Professionals
Information Professionals
Clinical Area
Anesthesiology
Geriatrics
Hospital Medicine
Surgery
Safety Target
Diagnostic Errors
Discontinuities, Gaps, and Hand-Off Problems
Postoperative Surgical Complications
Approach to Improving Safety
Regulation
Read Back Protocols
Structured Hand-offs
Checklists
Duty Hour Limitation
Culture of Safety
Clinical Information Systems
Origin/Sponsor
Agency for Healthcare Research and Quality (AHRQ)