Saying goodbye.

Ersilia M. DeFilippis

Commentary

Saying goodbye.

October 18, 2017

DeFilippis EM. JAMA Intern Med. 2017;177(11):1565.

View more articles from the same authors.

Handoffs can result in miscommunications and gaps in continuity, which can have adverse consequences on patient care. This commentary describes one physician's discomfort with the resident rotation process and its potential impact on patient safety.

PubMed citation

Available at

Related editorial

Related Resources From the Same Author(s)

Use of "Doctor" badges for physician role identification during clinical training.

September 11, 2019

Effectiveness of continuous or intermittent vital signs monitoring in preventing adverse events on general wards: a systematic review and meta-analysis.

October 12, 2016

Use of a standardized protocol to decrease medication errors and adverse events related to sliding scale insulin.

April 12, 2006

Systematic review of serious games for medical education and surgical skills training.

November 21, 2012

Mandatory reporting of impaired medical practitioners: protecting patients, supporting practitioners.

February 4, 2015

Using human error theory to explore the supply of non-prescription medicines from community pharmacies.

August 23, 2006

The science of safety improvement: learning while doing.

June 8, 2011

Patient safety and workplace bullying: an integrative review.

October 5, 2016

Eliciting the functional processes of apologizing for errors in health care: developing an explanatory model of apology.

June 14, 2017

Hardwiring patient blood management: harnessing information technology to optimize transfusion practice.

October 22, 2014

Reflection and analysis of how pharmacy students learn to communicate about medication errors.

June 24, 2009

Systems thinking for managing COVID-19 in health care systems: seven key messages.

September 23, 2020

Factors associated with wrong blood in tube errors: an international case series - The BEST collaborative study.

November 17, 2021

Using medical malpractice closed claims data to reduce surgical risk and improve patient safety.

April 25, 2007

Promising roles for pharmacists in addressing the U.S. opioid crisis.

February 14, 2018

Improving the reliability of verbal communication between primary care physicians and pediatric hospitalists at hospital discharge.

June 24, 2015

Medication safety program reduces adverse drug events in a community hospital.

June 22, 2005

Prevalence of error-prone abbreviations used in medication prescribing for hospitalised patients: multi-hospital evaluation.

May 2, 2012

Anesthetic mishaps: breaking the chain of accident evolution.

March 6, 2005

Physician satisfaction with transition from CPOE to paper-based prescription.

July 12, 2017

Training situational awareness to reduce surgical errors in the operating room.

February 25, 2015

Intensive care unit nurses' perceptions of safety after a highly specific safety intervention.

February 20, 2008

Defensive medicine among high-risk specialist physicians in a volatile malpractice environment.

June 8, 2005

Comprehensive evaluation of using computerised provider order-entry system for hospital discharge orders.

May 4, 2022

Administrative compensation for medical injuries: lessons from three foreign systems.

August 3, 2011

Using an inpatient portal to engage families in pediatric hospital care.

June 29, 2016

Patient safety in genomic medicine: an exploratory study.

April 13, 2016

The contribution of sociotechnical factors to health information technology–related sentinel events.

January 27, 2016

The medical liability climate and prospects for reform.

November 19, 2014

Psychological safety and infection prevention practices: results from a national survey.

February 19, 2020

Research designs for studies evaluating the effectiveness of change and improvement strategies.

March 6, 2005

A framework for health care organizations to develop and evaluate a safety scorecard.

November 7, 2007

Racial, ethnic, and socioeconomic disparities in estimates of AHRQ patient safety indicators.

April 21, 2005

Accident prevention in day-to-day clinical radiation therapy practice.

December 5, 2012

Perfusion safety: new initiatives and enduring principles.

October 19, 2011

Second victim support programs for healthcare organizations.

July 29, 2020

Improving patient safety in radiotherapy by learning from near misses, incidents and errors.

August 1, 2007

Insights from the sharp end of intravenous medication errors: implications for infusion pump technology.

April 21, 2005

Relationship between complaints and quality of care in New Zealand: a descriptive analysis of complainants and non-complainants following adverse events.

February 15, 2006

The impact of the 80-hour resident workweek on surgical residents and attending surgeons.

July 12, 2006

The surgical safety checklist and patient outcomes after surgery: a prospective observational cohort study, systematic review and meta-analysis.

March 7, 2018

Computerized surveillance for adverse drug events in a pediatric hospital.

October 7, 2009

Implementation of safeguards to improve patient safety in chemotherapy.

September 20, 2017

A review of healthcare failure mode and effects analysis (HFMEA) in radiotherapy.

November 16, 2016

Clinical handover of the critically ill postoperative patient: an integrative review.

April 15, 2015

Relationship between nursing home safety culture and Joint Commission accreditation.

May 2, 2012

Failure to rescue in neonatal care.

September 7, 2011

White paper on recommendation for systems-based practice competency.

December 6, 2017

Medication errors: an overview for clinicians.

September 17, 2014

Changes in practice and organisation surrounding blood transfusion in NHS trusts in England 1995-2005.

August 20, 2008

Development of the Leapfrog methodology for evaluating hospital implemented inpatient computerized physician order entry systems.

April 19, 2006

Medical errors: where are we now?

November 15, 2006

Medical monitoring for pharmaceutical injuries: tort law for the public's health?

March 6, 2005

Development and validation of the SURgical PAtient Safety System (SURPASS) checklist.

April 22, 2009

The incidence and nature of in-hospital adverse events: a systematic review.

June 18, 2008

Recognizing quality improvement and patient safety activities in academic promotion in departments of medicine: innovative language in promotion criteria.

July 13, 2016

Patient safety events reported in general practice: a taxonomy.

March 5, 2008

Understanding interdisciplinary health care teams: using simulation design processes from the Air Carrier Advanced Qualification Program to identify and train critical teamwork skills.

December 9, 2009

Creating effective quality-improvement collaboratives: a multiple case study.

February 16, 2011

Application of root cause analysis on malpractice claim files related to diagnostic failures.

December 15, 2010

Chemotherapy in home care: one team's performance improvement journey toward reducing medication errors.

October 12, 2011

Malpractice liability and health care quality: a review

February 19, 2020

Video capture of clinical care to enhance patient safety.

March 1, 2006

Nurses' perceptions of causes of medication errors and barriers to reporting.

December 20, 2006

Common formats allow uniform collection and reporting of patient safety data by patient safety organizations.

January 13, 2010

Risks of complications by attending physicians after performing nighttime procedures.

October 21, 2009

Effects of extended work shifts and shift work on patient safety, productivity, and employee health.

February 10, 2010

Medical error, malpractice and complications: a moral geography.

June 9, 2010

New research highlights the role of patient safety culture and safer care.

August 24, 2011

Level IV evidence—adverse anecdote and clinical practice.

July 27, 2011

Tragedy into policy: a quantitative study of nurses' attitudes toward patient advocacy activities.

June 22, 2011

Nurses' role in communication and patient safety.

July 8, 2009

The best medical care in the world.

May 16, 2018

Medication safety systems and the important role of pharmacists.

April 27, 2016

Improving pathologists' communication skills.

September 14, 2016

Patient safety: the what, how, and when.

November 18, 2015

Alleviating "second victim" syndrome: how we should handle patient harm.

December 14, 2011

Trends in health information technology safety: from technology-induced errors to current approaches for ensuring technology safety.

August 7, 2013

Non-Luer connectors: are we nearly there yet?

May 9, 2012

Unpredictable drug shortages: an ethical framework for short-term rationing in hospitals.

April 4, 2012

The lost art of doctoring: reflections of a pediatric resident.

November 15, 2017

Systematic approaches to adverse events in obstetrics, Part 1 & Part 2.

July 12, 2017

Safety interventions on the labor and delivery unit.

May 17, 2017

Root cause analysis for hospital-acquired pressure injury.

August 14, 2019

Teaching nurses to make clinical judgments that ensure patient safety.

August 14, 2019

Baccalaureate nursing students' accounts of medical mistakes occurring in the clinical setting: implications for curricula.

March 19, 2014

Reengineering hospital discharge: a protocol to improve patient safety, reduce costs, and boost patient satisfaction.

July 1, 2009

What 'patient-centered' should mean: confessions of an extremist.

June 3, 2009

2009 National Patient Safety Goals.

April 15, 2009

CMS's hospital-acquired condition lists link hospital payment, patient safety.

March 25, 2009

A longitudinal study on the impact of simulation on positive deviance through speaking up.

November 30, 2022

I-PASS handover system: a decade of evidence demands action.

May 12, 2021

Diagnostic excellence through the lens of patient-centeredness.

December 8, 2021

Advancing a More Health-Literate Approach to Patient Safety

October 9, 2019

IT vulnerabilities highlighted by errors, malfunctions at veterans' medical centers.

March 18, 2009

Patient safety organizations ready for action.

February 18, 2009

IOM: shorten residents' work shifts to reduce fatigue, improve patient safety.

January 28, 2009

The importance of simulation: preventing hand-off mistakes.

October 29, 2008

Pediatric medication safety in the emergency department.

August 27, 2008

New patient safety organizations lower roadblocks to medical error reporting.

August 13, 2008

Related Resources

Patient Safety Innovations

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

July 31, 2023

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

June 28, 2023

WebM&M Cases

Critical Echocardiogram Result Lost to Follow-up.

June 14, 2023

Patient Safety Innovations

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

May 31, 2023

Patient Safety Innovations

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

May 31, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Perspective

Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions

November 16, 2022

Interview

In Conversation With... Pascale Carayon, PhD and Nicole Werner, PhD

November 16, 2022

Patient handoffs.

June 15, 2022

Influence of perioperative handoffs on complications and outcomes.

November 17, 2021

Listening and question-asking behaviors in resident and nurse handoff conversations: a prospective observational study.

April 1, 2020

Dynamic pocket card for implementing ISBAR in shift handover communication.

October 23, 2019

A randomized experimental study to assess the effect of language on medical students' anxiety due to uncertainty.

August 21, 2019

I-PASS mentored implementation handoff curriculum: champion training materials.

March 13, 2019

I-PASS Mentored Implementation Handoff Curriculum: implementation guide and resources.

March 10, 2019

WebM&M Cases

Duplicate Insulin Order

March 1, 2019

Using a potentially aggressive/violent patient huddle to improve health care safety.

January 30, 2019

Perioperative medication errors: uncovering risk from behind the drapes.

January 16, 2019

Impact of the communication and patient hand-off tool SBAR on patient safety: a systematic review.

November 28, 2018

Defining minimum necessary anticoagulation-related communication at discharge: Consensus of the Care Transitions Task Force of the New York State Anticoagulation Coalition.

November 7, 2018

I-PASS handoff program: use of a campaign to effect transformational change.

August 15, 2018

Preparing clinicians for transitioning patients across care settings and into the home through simulation.

July 25, 2018

A standardized handoff simulation promotes recovery from auditory distractions in resident physicians.

July 11, 2018

Diagnostic discordance, health information exchange, and inter-hospital transfer outcomes: a population study.

June 20, 2018

A call to bridge across silos during care transitions.

May 30, 2018

Innovative approach to reconstruct bedside handoff: using simple rules of complexity science to promote partnership with patients.

May 30, 2018

Improving patient safety in public hospitals: developing standard measures to track medical errors and process breakdowns.

April 4, 2018

Results of an enhanced clinic handoff and resident education on resident patient ownership and patient safety.

March 21, 2018

Resident shift handoff strategies in US internal medicine residency programs.

March 14, 2018

WebM&M Cases

Signout Fallout

February 1, 2018

See More About The Topic

Hospitals

Health Care Providers

Medicine

Discontinuities, Gaps, and Hand-Off Problems

Active Errors

Saying goodbye.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Saying goodbye.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Preventing Falls Through Patient and Family Engagement to Create Customized Prevention Plans

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

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