Handoffs and fumbles. | PSNet

Provide Feedback |

Submit a Case

Register

Book/Report

Handoffs and fumbles.

March 27, 2005

Wachter RM, Shojania KG. Chapter in: Wachter RM, Shojania KG. Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes. New York, NY: Rugged Land, LLC; 2004.

Personal stories illustrate the systems issues that contribute to mismanagement of patients as they move from provider to provider throughout the health care system.

Free full text (registration required)

Related Resources From the Same Author(s)

Understanding Patient Safety, Third Edition.

May 23, 2012

Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes. Updated edition.

March 27, 2005

Diagnosis: Reducing Errors and Improving Quality.

November 2, 2022

The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age.

April 1, 2015

Learning how to learn: compliance with patient safety alerts in the NHS.

August 3, 2005

Lost Mothers: Maternal Care and Preventable Deaths.

November 8, 2017

Better: A Surgeon's Notes on Performance.

April 11, 2007

Operating at the sharp end: the complexity of human error.

March 6, 2005

Mistaking error.

March 27, 2005

Medication reconciliation in the hospital: what, why, where, when, who and how?

May 2, 2012

All in Her Head. The Truth and Lies Early Medicine Taught Us About Women's Bodies and Why It Matters Today.

March 20, 2024

Surgical Patient Safety: A Case-Based Approach.

October 18, 2017

Doing Harm.

April 11, 2018

Safer Healthcare: Strategies for the Real World.

February 24, 2016

Black Box Thinking: Why Most People Never Learn From Their Mistakes—But Some Do.

January 13, 2016

Maternal Health of Women and Girls of African Descent in the Americas.

July 26, 2023

Unwell Women: Misdiagnosis and Myth in a Man-Made World.

June 23, 2021

Legacy: a Black Physician Reckons with Racism in Medicine.

March 6, 2024

Why Things Bite Back: Technology and the Revenge of Unintended Consequences.

March 27, 2005

The Design of Everyday Things.

March 27, 2005

Patient Safety and the "Just Culture": A Primer for Health Care Executives.

March 27, 2005

The Checklist Manifesto: How to Get Things Right.

January 13, 2010

Safer Hospital Care: Strategies for Continuous Innovation, Second Edition.

May 16, 2019

Every Patient Tells A Story: Medical Mysteries and the Art of Diagnosis.

August 26, 2009

Snowball in a Blizzard: A Physician's Notes on Uncertainty in Medicine.

March 30, 2016

Unaccountable: What Hospitals Won't Tell You and How Transparency Can Revolutionize Health Care.

September 26, 2012

Patient Safety: An Engineering Approach.

November 23, 2011

Deep Medicine: How Artificial Intelligence Can Make Healthcare Human Again.

March 20, 2019

The Best Practice: How the New Quality Movement Is Transforming Medicine.

November 5, 2008

Committed to Safety: Ten Case Studies on Reducing Harm to Patients.

May 10, 2006

The Fifth Discipline: The Art & Practice of The Learning Organization. Revised & Updated Edition.

March 27, 2005

Complications: A Surgeon's Notes on an Imperfect Science.

March 27, 2005

The High Costs of Weak Compliance With the New York State Hospital Adverse Event Reporting and Tracking System.

March 25, 2009

September 23, 2009

Are Workarounds Ethical? Managing Moral Problems in Health Care Systems.

February 3, 2016

Do No Harm: Stories of Life, Death, and Brain Surgery.

June 17, 2015

Monday Mornings.

April 11, 2012

Error and Uncertainty in Diagnostic Radiology.

March 20, 2019

The Cognitive Autopsy: A Root Cause Analysis of Medical Decision Making.

January 27, 2021

Misadventures in Health Care: Inside Stories.

August 24, 2005

Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out.

March 10, 2010

Keeping the Commitment: A Progress Report on Four Early Leaders in Patient Safety Improvement.

March 30, 2011

Insurers' Medical Loss Ratios and Quality Improvement Spending in 2011.

April 10, 2013

Clinical Uncertainty in Primary Care: The Challenge of Collaborative Engagement.

March 5, 2014

Confronting Racism in Health Care: Moving from Proclamations to New Practices.

December 1, 2021

Fragmented: A Doctor's Quest to Piece Together American Health Care.

September 27, 2023

End Sepsis.

September 7, 2016

Transparency and public reporting are essential for a safe health care system.

April 7, 2010

The Invisible Gorilla: and Other Ways Our Intuitions Deceive Us.

August 11, 2010

Listening for What Matters: Avoiding Contextual Errors in Health Care.

March 9, 2016

Meltdown: Why Our Systems Fail and What We Can Do About It.

February 6, 2019

Around the Patient Bed: Human Factors and Safety in Health Care.

October 23, 2013

When Doctors Don't Listen.

January 23, 2013

Errors in Organizations.

August 1, 2012

Closing Death’s Door: Legal Innovations to End the Epidemic of Healthcare Harm.

July 7, 2021

Still Not Safe: Patient Safety and the Middle-Managing of American Medicine.

December 18, 2019

Health Care Opinion Leaders' Views on the Quality and Safety of Health Care in the United States.

August 15, 2007

Building a Culture of Patient Safety Through Simulation: An Interprofessional Learning Model.

June 10, 2015

Global Patient Safety: Law, Policy and Practice.

August 14, 2019

Fatal Solutions: How a Healthcare System Used Tragedy to Transform Itself and Redefine Just Culture.

October 5, 2022

Mirror, Mirror on the Wall: An Update on the Quality of American Health Care Through the Patient's Lens.

April 12, 2006

The Basics of FMEA. 2nd ed.

March 27, 2005

Economic Analysis of Medical Malpractice Liability and Its Reform.

July 24, 2013

Mirror, Mirror 2021: Reflecting Poorly

August 1, 2021

Implementing Patient Safety: Addressing Culture, Conditions and Values to Help People Work Safely.

October 23, 2019

Zero Harm: How to Achieve Patient and Workforce Safety in Healthcare.

July 31, 2019

Quality and Safety in Anesthesia and Perioperative Care.

July 17, 2019

How Discrimination in Health Care Affects Older Americans, and What Health Systems and Providers Can Do.

May 4, 2022

Revealing Disparities: Health Care Workers’ Observations of Discrimination Against Patients.

February 28, 2024

Framework for a High Performance Health System for the United States.

August 30, 2006

Diffusion of Innovations. 5th ed.

March 27, 2005

Making Health Care Safer: A Critical Review of Modern Evidence Supporting Strategies to Improve Patient Safety.

March 6, 2013

HANYS' Report on Report Cards.

November 20, 2019

The Girl Who Died Twice: Every Patient's Nightmare: the Libby Zion Case and the Hidden Hazards of Hospitals.

March 27, 2005

Patient Safety: Research into Practice.

September 13, 2006

Resilient Health Care Series.

September 16, 2015

Dead by Mistake.

August 19, 2009

Getting Your Best Health Care: Real-World Stories for Patient Empowerment.

April 27, 2011

Health Care Leader Action Guide to Reduce Avoidable Readmissions.

February 10, 2010

Medication safety technologies: what is and is not working.

July 29, 2009

The bell curve.

March 6, 2005

High Reliability Organizations: A Healthcare Handbook for Patient Safety & Quality.

May 25, 2016

Why King-Harbor must die.

July 11, 2007

Looking back on the history of patient safety: an opportunity to reflect and ponder future challenges.

November 3, 2021

Association between in-clinic opioid administration and discharge opioid prescription in urgent care: a retrospective cohort study.

February 17, 2021

The threat within: mitigating the risk of medical error.

March 25, 2020

Effects of rapid response systems on clinical outcomes: systematic review and meta-analysis.

January 2, 2008

Strategies to improve patient safety: the evidence base matures.

March 6, 2013

Incident reporting systems: what will it take to make them less frustrating and achieve anything useful?

December 1, 2021

Under the Skin. The Hidden Toll of Racism on American Lives and on the Health of our Nation.

June 29, 2022

Right Kind of Wrong: Why Learning to Fail can Teach us to Thrive.

October 18, 2023

Classifying laboratory incident reports to identify problems that jeopardize patient safety.

September 7, 2005

Assessing the Evidence for Context-Sensitive Effectiveness and Safety of Patient Safety Practices: Developing Criteria.

June 8, 2011

The Emperor’s New Clothes: Or Whatever Happened To “Human Error”?

January 1, 2001

Putting out fires: a qualitative study exploring the use of patient complaints to drive improvement at three academic hospitals.

July 10, 2019

Loud wake-up call: unlabeled containers lead to patient’s death.

March 27, 2005

A health system that won't learn from its mistakes.

September 21, 2022

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

September 15, 2010

Striving for diagnostic excellence.

August 30, 2023

Sorry Works! 2.0: Disclosure, Apology, and Relationships Prevent Medical Malpractice Claims.

March 12, 2008

View More

Related Resources

Targeted Medication Safety Best Practices for Hospitals.

February 22, 2024

Diagnostic Safety Across Transitions of Care Throughout the Healthcare System: Current State and a Call to Action.

June 28, 2023

Patient Safety Authority Annual Reports.

May 1, 2023

National Safety Standards for Invasive Procedures (NatSSIPs2).

February 7, 2023

Guiding Principles to Achieve Continuity in Medication Management.

December 1, 2022

Diagnosis: Reducing Errors and Improving Quality.

November 2, 2022

Deficiencies in Inpatient Mental Health Care Coordination and Processes Prior to a Patient's Death by Suicide, Harry S. Truman Memorial Veterans' Hospital in Columbia, Missouri.

February 10, 2021

Speaking up about patient-perceived serious visit note errors: patient and family experiences and recommendations.

January 13, 2021

Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being.

November 6, 2019

Independent Review of Gross Negligence Manslaughter and Culpable Homicide.

July 17, 2019

Medication Safety in Key Action Areas.

July 10, 2019

The STOP Measure. Safe and Transparent Opioid Prescribing to Promote Patient Safety and Reduced Risk of Opioid Misuse.

July 1, 2019

An opportunity to engage obstetrics and gynecology patients through shared visit notes.

June 26, 2019

Chasing zero harm in radiation oncology: using pre-treatment peer review.

May 22, 2019

Evaluation of medication errors at the transition of care from an ICU to non-ICU location.

March 27, 2019

Doing Harm.

April 11, 2018

Ignoring the Alarms: How NHS Eating Disorder Services Are Failing Patients.

March 28, 2018

The Report of the Short Life Working Group on Reducing Medication-related Harm.

March 28, 2018

Patient Deaths at Arbour Health Systems—Westwood Lodge Hospital and Pembroke Hospital.

March 21, 2018

Toolkit to Engage High-Risk Patients in Safe Transitions Across Ambulatory Settings.

January 10, 2018

Global Guidelines on the Prevention of Surgical Site Infection.

January 3, 2018

Closing the Loop: A Guide to Safer Ambulatory Referrals in the EHR Era.

December 13, 2017

Alterations in Spanish language interpretation during pediatric critical care family meetings.

December 6, 2017

Prescription Opioids: Medicare Needs to Expand Oversight Efforts to Reduce the Risk of Harm.

November 22, 2017

Clearing the Error: Using Public Deliberation to Define Patient Roles as Partners in the Diagnostic Process.

November 8, 2017

Saying goodbye.

October 18, 2017

Clinician perspectives on the management of abnormal subcritical tests in an urban academic safety-net health care system.

October 4, 2017

Increasing patient safety with neonates via handoff communication during delivery: a call for interprofessional health care team training across GME and CME.

August 30, 2017

Intraoperative handoffs among anesthesia providers increase the incidence of documentation errors for controlled drugs.

August 9, 2017

Assigning responsibility to close the loop on radiology test results.

July 12, 2017

View More

See More About The Topic

Health Care Providers

Discontinuities, Gaps, and Hand-Off Problems

To sign up for updates or to access your subscriber preferences, please enter your email address below.

5600 Fishers Lane
Rockville, MD 20857
Telephone: (301) 427-1364