Care transitions present opportunities for errors. This issue brief highlights the risk of diagnostic errors during transitions in care, such as from the emergency department to the inpatient floor or from inpatient to outpatient care. The brief describes strategies to prevent and reduce these errors, such as diagnostic feedback or structured handoff tools.

Originally published in 2005, these Guiding Principles outlines 10 guiding principles to support medication management as patients transfer from one care environment to another, both within one care setting (e.g., hospital) and between care settings (e.g., hospital to long term care). The Guiding Principles are person centered, equity, and coordination and collaboration.

Surgical specimen and laboratory process problems can affect diagnosis. This publication examines factors that contribute to errors across the surgical pathology process and reviews strategies to reduce their impact on care. Chapters discuss areas of focus to encourage process improvement and error response, such as information technology, specimen tracking, root cause analysis, and disclosure.

Reducing adverse medication events is a worldwide challenge. This collection of technical reports explores key areas of concern that require action at a system level to improve: high-alert medications, polypharmacy, and medication use at care transitions. Each monograph provides an overview of the topic as well as practical improvement approaches for patients, clinicians, and organizations.

Programs are in place to address hospital discharge process gaps that contribute to readmissions. This report summarizes research on primary care perspectives on reducing readmissions. Interventions identified include automated alerting to primary care providers when patients are hospitalized and the patient-centered medical home model.

Transitions are known to be vulnerable to communication errors. This toolkit focuses on patient transitions between ambulatory care environments and encourages staff to engage patients and families in their care to prevent errors during care transitions.

Poor communication can contribute to medical error, but incident analysis often fails to identify particular elements of communication associated with the error. This publication discusses factors that influence communication in the medical care process and uses case studies to illustrate how effective communication can help prevent and address close calls and adverse events.

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.

This online resource provides instructions and templates for implementing team-based, collaborative care. This group's collaborative care model has received a John M. Eisenberg Award for contributions to patient safety.

Health literacy can affect patients' ability to understand directions, ask good questions, and participate in care. Framing health literacy as a public health challenge, this report describes efforts to address it in three states and explores implementation and research to improve it across the United States.

This government report reveals the need for a policy to ensure that veterans' medication needs are safely managed during transitions between health care providers.

This report discusses the need for improved coordination and integration in patient care to reduce preventable errors.

This series, developed in conjunction with the STAAR initiative, provides tactics and resources to improve transitions across various care settings.

This guide discusses the impact of poor communication on care transitions and describes tactics for improvement.

This report analyzed how medication information is shared among UK practices and patients after a hospital stay and found that 81% of general practices thought that patient information given to them from hospitals was incomplete or inaccurate.

This book provides an introduction to key patient safety topics and includes a set of 20 case studies to demonstrate opportunities for error prevention.

This report shares findings from a 5-year analysis of the state of health care in the United Kingdom. It reveals that while awareness of patient safety has improved since the first report in the series, the UK health system needs to be more consistent in its application of patient-centeredness concepts to fully promote quality.

The process of transferring primary responsibility for patient care is commonly referred to as a handoff. Handoffs are inherently dangerous times for patient safety due to discontinuity of providers and care delivery. This book offers health care organizations step-by-step instructions, sample forms, and insights to help standardize the patient transfer process. The book provides tips for implementing the SBAR (Situation-Background-Assessment-Recommendation) method, which has become widely accepted as a signout tool. The Accreditation Council for Graduate Medical Education requires residency programs to address safe handoffs during training. An AHRQ WebMM commentary discussed the dangers of suboptimal handoffs.