Critical conversations: a call for a nonprocedural "time out."

Niraj L Sehgal; Michael Fox; Bradley Sharpe; Arpana Vidyarthi; Mary A Blegen; Robert Wachter

Commentary

Critical conversations: a call for a nonprocedural "time out."

April 27, 2011

Sehgal NL, Fox M, Sharpe B, et al. J Hosp Med. 2011;6(4):225-30.

View more articles from the same authors.

This commentary describes a structured communication strategy that targets discussions at time of admission, change in clinical condition, and time of discharge, to reduce communication failures and improve patient safety.

PubMed citation

Available at

Related Resources From the Same Author(s)

A multidisciplinary teamwork training program: The Triad for Optimal Patient Safety (TOPS) experience.

October 15, 2008

Patient whiteboards as a communication tool in the hospital setting: A survey of practices and recommendations.

May 5, 2010

I-CaRe: a case review tool focused on improving inpatient care.

February 4, 2009

Effects of a multicentre teamwork and communication programme on patient outcomes: results from the Triad for Optimal Patient Safety (TOPS) project.

January 30, 2005

AHRQ's Hospital Survey on Patient Safety Culture: psychometric analyses.

October 21, 2009

Identification of inpatient DNR status: a safety hazard begging for standardization.

January 2, 2008

The impact of duty hours on resident self reports of errors.

March 7, 2007

Inability of providers to predict unplanned readmissions.

April 6, 2011

Perspective: a road map for academic departments to promote scholarship in quality improvement and patient safety.

January 30, 2005

Interventions for postsurgical opioid prescribing: a systematic review.

September 19, 2018

Enculturation of unsafe attitudes and behaviors: student perceptions of safety culture.

May 15, 2013

Complementary telephone strategies to improve postdischarge communication.

September 14, 2011

Improving safety culture on adult medical units through multidisciplinary teamwork and communication interventions: the TOPS Project.

August 18, 2010

Quality improvement and patient safety activities in academic departments of medicine.

October 31, 2012

Competence and certification of registered nurses and safety of patients in intensive care units.

March 18, 2009

Empowering frontline nurses: a structured intervention enables nurses to improve medication administration accuracy.

November 25, 2009

Engaging residents and fellows to improve institution-wide quality: the first six years of a novel financial incentive program.

April 30, 2014

The relationship between hospital systems load and patient harm.

September 10, 2014

Factors associated with intern fatigue.

October 8, 2008

House staff team workload and organization effects on patient outcomes in an academic general internal medicine inpatient service.

January 17, 2007

The association of patient safety climate and nurse-related organizational factors with selected patient outcomes: a cross-sectional survey.

June 27, 2012

Interdisciplinary teamwork in hospitals: a review and practical recommendations for improvement.

November 16, 2011

Bridging the gap: a framework and strategies for integrating the quality and safety mission of teaching hospitals and graduate medical education.

June 17, 2015

Shifting indirect patient care duties to after hours in the era of work hours restrictions.

May 11, 2011

Potential unintended consequences due to Medicare's "No Pay for Errors Rule"? A randomized controlled trial of an educational intervention with internal medicine residents.

June 23, 2010

Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out.

December 5, 2007

Documenting quality improvement and patient safety efforts: the quality portfolio. A statement from the Academic Hospitalist Taskforce.

July 17, 2013

Resolving the productivity paradox of health information technology: a time for optimism.

June 6, 2018

Impact of duty-hour restriction on resident inpatient teaching.

October 28, 2009

Role-modeling and medical error disclosure: a national survey of trainees.

February 12, 2014

Personal accountability in healthcare: searching for the right balance.

September 12, 2012

Patient safety at ten: unmistakable progress, troubling gaps.

December 2, 2009

Could computerization harm patient safety?

July 12, 2006

Expected and unanticipated consequences of the quality and information technology revolutions.

June 21, 2006

Bridging leadership roles in quality and patient safety: experience of 6 US academic medical centers.

March 22, 2017

Progress in patient safety: a glass fuller than it seems.

August 28, 2013

Balancing "no blame" with accountability in patient safety.

October 7, 2009

Forum: The 100,000 Lives Campaign: a scientific and policy review [with IHI response].

November 1, 2006

Academic year-end transfers of outpatients from outgoing to incoming residents: an unaddressed patient safety issue.

September 30, 2009

Applying Toyota Production System principles to a psychiatric hospital: making transfers safer and more timely.

September 2, 2009

The faces of errors: a case-based approach to educating providers, policy makers, and the public about patient safety.

March 6, 2005

Financial incentives and mortality: taking pay for performance a step too far.

March 16, 2016

Project BOOST: effectiveness of a multihospital effort to reduce rehospitalization.

August 21, 2013

Improving follow-up of high-risk psychiatry outpatients at resident year-end transfer.

January 30, 2005

Effective physician–nurse communication: a patient safety essential for labor and delivery.

January 30, 2005

Bringing diagnosis into the quality and safety equations.

October 3, 2012

Computerised provider order entry combined with clinical decision support systems to improve medication safety: a narrative review.

April 30, 2014

Responsibility for quality improvement and patient safety: hospital board and medical staff leadership challenges.

July 21, 2010

The wisdom and justice of not paying for "preventable complications."

May 14, 2008

Medicare's decision to withhold payment for hospital errors: the devil is in the details.

January 30, 2008

Tracking progress in patient safety: an elusive target.

August 16, 2006

Project BOOST implementation: lessons learned.

September 10, 2014

Improving the quality and safety of care on the medical ward: a review and synthesis of the evidence base.

January 14, 2015

Public reporting of antibiotic timing in patients with pneumonia: lessons from a flawed performance measure.

July 16, 2008

US internal medicine program director perceptions of alignment of graduate medical education and institutional resources for engaging residents in quality and safety.

August 22, 2018

Rethinking medical ward quality.

November 9, 2016

Refocusing the lens: patient safety in ambulatory chronic disease care.

July 1, 2009

Patient safety is not elective: a debate at the NPSF Patient Safety Congress.

December 3, 2014

Responding to clinicians who fail to follow patient safety practices: perceptions of physicians, nurses, trainees, and patients.

January 22, 2014

Accountability measures—using measurement to promote quality improvement.

June 30, 2010

Advancing the next generation of handover research and practice with cognitive load theory.

January 27, 2016

Development of a high-value care culture survey: a modified Delphi process and psychometric evaluation.

November 16, 2016

Hospital-initiated transitional care interventions as a patient safety strategy: a systematic review.

March 20, 2013

High-profile investigations into hospital safety problems in England did not prompt patients to switch providers.

March 21, 2012

Associations between internet-based patient ratings and conventional surveys of patient experience in the English NHS: an observational study.

July 11, 2012

Frailty and potentially inappropriate prescribing in older people with polypharmacy: a bi-directional relationship?

August 31, 2022

"July Effect": impact of the academic year-end changeover on patient outcomes. A systematic review.

July 27, 2011

Effects of interdisciplinary team care interventions on general medical wards: a systematic review.

June 24, 2015

Creating champions for health care quality and safety.

January 6, 2010

Pragmatic insights on patient safety priorities and intervention strategies in ambulatory settings.

December 6, 2017

National hospital ratings systems share few common scores and may generate confusion instead of clarity.

March 11, 2015

No excuses: the reality that demands action.

September 1, 2005

Using participatory design to engage physicians in the development of a provider-level performance dashboard and feedback system.

February 2, 2022

Findings from the ISMP Medication Safety Self-Assessment for hospitals.

March 6, 2005

Why diagnostic errors don't get any respect--and what can be done about them.

September 15, 2010

The end of the beginning: patient safety five years after 'To Err Is Human.'

March 6, 2005

Medical and surgical comanagement after elective hip and knee arthroplasty: a randomized, controlled trial.

March 6, 2005

Safety in numbers: the development of Leapfrog's composite patient safety score for US hospitals.

October 16, 2013

What context features might be important determinants of the effectiveness of patient safety practice interventions?

June 29, 2011

The role of theory in research to develop and evaluate the implementation of patient safety practices.

January 30, 2005

White paper on recommendation for systems-based practice competency.

December 6, 2017

Nursing student medication errors: a case study using root cause analysis.

May 1, 2013

How does context affect interventions to improve patient safety? An assessment of evidence from studies of five patient safety practices and proposals for research.

May 4, 2011

Medication, allergy, and adverse drug event discrepancies in ambulatory care.

March 26, 2008

A framework for classifying patient safety practices: results from an expert consensus process.

January 30, 2005

Neurobehavioral performance of residents after heavy night call vs after alcohol ingestion.

September 14, 2005

Transforming concepts in patient safety: a progress report.

August 1, 2018

How hospitals select their patient safety priorities: an exploratory study of four Veterans Health Administration hospitals.

September 25, 2019

Strategies to improve patient safety: the evidence base matures.

March 6, 2013

Opportunities to mine EHRs for malpractice risk management and patient safety.

September 7, 2022

Clinical scenarios: enhancing the skill set of the nurse as a vigilant guardian.

September 15, 2010

Decimal numbers and safe interpretation of clinical pathology results.

April 16, 2014

Prescribing errors in children: why they happen and how to prevent them.

June 14, 2023

Safety competency: exploring the impact of environmental and personal factors on the nurse's ability to deliver safe care.

October 19, 2022

Effect of nonpayment for hospital-acquired, catheter–associated urinary tract infection: a statewide analysis.

September 19, 2012

Defining diagnostic error: a scoping review to assess the impact of the National Academies' report Improving Diagnosis in Health Care.

May 25, 2022

The impact of prolonged continuous wakefulness on resident clinical performance in the intensive care unit: a patient simulator study.

March 3, 2010

A checklist-based intervention to improve surgical outcomes in Michigan: evaluation of the Keystone Surgery program.

January 28, 2015

Attitudes toward safety and teamwork in a maternity unit with embedded team training.

November 3, 2010

Attitudes of health sciences faculty members towards interprofessional teamwork and education.

September 5, 2007

Related Resources

Emotional responses and support needs of healthcare professionals after adverse or traumatic experiences in healthcare-evidence from seminars on peer support.

June 28, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Patient Safety Primers

Debriefing for Clinical Learning

November 18, 2021

“I made a mistake!”: a narrative analysis of experienced physicians' stories of preventable error.

January 20, 2021

WebM&M Cases

Code Status vs. Care Status

December 23, 2020

Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors.

October 24, 2018

Learning From Mistakes.

August 31, 2016

Giving voice to quality and safety matters at board level: a qualitative study of the experiences of executive nurses working in England and Wales.

August 24, 2016

Peer support for clinicians: a programmatic approach.

July 20, 2016

Towards safer transitions: a curriculum to teach and assess hospital-to-hospice handoffs.

June 15, 2016

Why do we still page each other? Examining the frequency, types and senders of pages in academic medical services.

February 3, 2016

Debriefing in the emergency department after clinical events: a practical guide.

December 17, 2014

Sociocultural factors influencing incident reporting among physicians and nurses: understanding frames underlying self- and peer-reporting practices.

October 15, 2014

Effective communication with primary care providers.

October 1, 2014

The influence of organizational factors on patient safety: examining successful handoffs in health care.

August 27, 2014

'Saying it without words': a qualitative study of oncology staff's experiences with speaking up about safety concerns.

June 11, 2014

We need to talk: an observational study of the impact of electronic medical record implementation on hospital communication.

March 19, 2014

Recognizing and managing errors of cognitive underspecification.

March 19, 2014

Redesigning hospital alarms for patient safety: alarmed and potentially dangerous.

March 12, 2014

Medical disrespect.

February 12, 2014

Assigning a team-based pager for on-call physicians reduces paging errors in a large academic hospital.

February 12, 2014

Socio-technical issues and challenges in implementing safe patient handovers: insights from ethnographic case studies.

February 12, 2014

Successful implementation of standardized multidisciplinary bedside rounds, including daily goals, in a pediatric ICU.

February 5, 2014

An exploratory study of knowledge brokering in hospital settings: facilitating knowledge sharing and learning for patient safety?

January 29, 2014

Speaking up about the dangers of the hidden curriculum.

January 22, 2014

Sign-out snapshot: cross-sectional evaluation of written sign-outs among specialties.

January 15, 2014

The concept of shared mental models in healthcare collaboration.

December 11, 2013

Developing a medical emergency team running sheet to improve clinical handoff and documentation.

December 11, 2013

An intervention model that promotes accountability: peer messengers and patient/family complaints.

October 9, 2013

'You talking to me?' Docs and feedback.

September 18, 2013

See More About The Topic

Hospitals

Quality and Safety Professionals

Organizational Behaviorists

General Internal Medicine

Hospital Medicine

Critical conversations: a call for a nonprocedural "time out."

Debriefing for Clinical Learning

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Critical conversations: a call for a nonprocedural "time out."

Debriefing for Clinical Learning

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

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