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The Patient Safe-D(ischarge) program used standardized tools to educate patients about their discharge needs, test understanding of those needs, and improve medication reconciliation at admission and discharge. A quasi-randomized controlled trial of the program found that it significantly increased patients' understanding and knowledge of their diagnoses, treatment, and required follow-up care.

Formerly known as the Antenatal and Neonatal Guidelines, Education and Learning System (ANGELS), the University of Arkansas for Medical Sciences (UAMS) High-Risk Pregnancy Program links clinicians and patients across the state with UAMS, where the vast majority of the state's high-risk pregnancy services, maternal-fetal medicine specialists, and prenatal genetic counselors are located.

The Support and Services at Home (SASH®) program provides onsite assistance to help senior citizens (and other Medicare beneficiaries) remain in their homes as they age. Using evidence-based practices, a multidisciplinary, onsite team conducts an initial health assessment, creates an individualized care plan based on each participant’s self-identified goals, provides onsite nursing and care coordination with local partners, and schedules community activities to support health and wellness.

O'Toole JK, Starmer AJ, Calaman S, et al. MedEdPORTAL. 2018;14:10736.
The I-PASS structured handoff tool intends to reduce errors and preventable adverse events. This article describes the development of the I-PASS Mentored Implementation Guide. The guide was considered by I-PASS sites essential, particularly the sections on the I-PASS curriculum and handoff observations.
Riley W, Begun JW, Meredith L, et al. Health Serv Res. 2016;51:2431-2452.
Prior research has shown that reducing preventable perinatal harm leads to a decrease in malpractice claims. In this prospective study involving the perinatal units across 14 hospitals from 12 states and accounting for almost 350,000 deliveries, researchers found that successful implementation of 3 standard care processes resulted in a 14% decrease in harm in perinatal care from the baseline period.
Farmer B. Emerg Med (N Y). 2016;48.
Emergency departments are high-risk environments due to the urgency of care needs and complexity of communication. This commentary explores challenges associated with medication administration, handoffs, discharge processes, and electronic health records in emergency medicine and recommends strategies to reduce risks.
Boutwell A, Bourgoin A , Maxwell J, et al. Rockville, MD: Agency for Healthcare Research and Quality; September 2016. AHRQ Publication No. 16-0047-EF.
This toolkit provides information for hospitals to help reduce preventable readmissions among Medicaid patients. Building on hospital experience with utilizing the materials since 2014, this updated guide explains how to determine root causes for readmissions, evaluate existing interventions, develop a set of improvement strategies, and optimize care transition processes.
Rockville, MD: Agency for Healthcare Research and Quality; September 2016. AHRQ Publication No. 16-0035-2-EF.
Patient safety in ambulatory care is receiving increased attention. This guide includes case studies that explore how Open Notes, team-based care delivery, and patient and family advisory committees have shown promise as patient engagement and safety improvement mechanisms in primary care settings.
American Hospital Association; AHA.
Hospitals and health systems face challenges in implementing electronic health records that can affect safety. This webinar introduced the SAFER guides, which highlight strategies to improve safety related to electronic health record use, and educate participants about ways to implement these guides in their organizations. The session featured Hardeep Singh and Dean F. Sittig as speakers.
Crisp H, ed. London, UK: BMJ Publishing Group Ltd; ISSN: 2399-6641.
This journal provides access to a collection of practice reports on patient safety and quality improvement initiatives in the United Kingdom. 
Koch PE, Simpson D, Toth H, et al. Academic Medicine. 2014;89.
This qualitative analysis of medical students' perceptions revealed persistent concerns related to the safety of transitions in care, despite much attention and recommendations related to improving handoffs. The most common cause of frustration among students was poor communication, which included unclear discussion about responsibilities, incomplete explanation regarding patients' needs, and inadequate identification of health care workers involved with the handoff.
Hansen LO, Strater A, Smith L, et al. BMJ Qual Saf. 2011;20:773-8.
Communication between hospital-based and outpatient physicians is often suboptimal, and is thought to play a role in precipitating adverse events after discharge and rehospitalizations. However, this case-control study found that performance of several aspects of discharge communication—including medication reconciliation, discharge summary completion and quality, and patient education—did not decrease the risk of readmission. Other studies of specific discharge interventions, such as arranging outpatient follow-up or pharmacist review of medications, have also not affected readmission rates, meaning that preventable readmissions may only be reduced through more comprehensive (and resource-intensive) programs.
Landro L. Wall Street Journal. March 28, 2011.
This newspaper article discusses how combining best practices in teamwork, simulation, and communication can improve patient safety during obstetric emergencies.

Baker GR, ed. Healthc Q. 2010;13(Spec No):1-136.  

This is the fifth in a series of special issues devoted to exploring Canadian patient safety organizational and strategic improvement efforts. The articles highlight work related to topics including critical occurrence review, hand hygiene compliance, and effective handoffs.
Thomas J. Nasca, MD, is the executive director and chief executive officer of the Accreditation Council for Graduate Medical Education (ACGME). Prior to joining the ACGME in 2007, Dr. Nasca, a nephrologist, was dean of Jefferson Medical College and Senior Vice President for Academic Affairs of Thomas Jefferson University. We asked him to speak with us about the role of the ACGME in patient safety.
Shafiq J, Barton M, Noble D, et al. Radiother Oncol. 2009;92:15-21.
Radiation oncology is one of the more technologically sophisticated fields in medicine, requiring close collaboration between physicians, technologists, and medical physicists. High-profile errors in this field have been attributed to rapidly changing technology and human factors, and this review sought to characterize the types and frequency of errors and near misses in routine radiotherapy practice using data from voluntary error databases as well as published literature. Although the overall incidence of errors appears low, most reported errors were considered preventable, as they occurred due to faulty information transfer. The authors discuss the types of errors that may occur at each stage of radiotherapy and recommend error prevention strategies.