Transfer of accountability: transforming shift handover to enhance patient safety.

Kim Alvarado; Ruth Lee; Emily Christoffersen; Nancy Fram; Sheryl Boblin; Nancy Poole; Janie Lucas; Shirley Forsyth

Commentary

Transfer of accountability: transforming shift handover to enhance patient safety.

November 22, 2006

Alvarado K, Lee R, Christoffersen E, et al. Healthc Q. 2006;9 Spec No:75-79.

View more articles from the same authors.

The authors describe one hospital's initiative to develop evidence-based handoff guidelines, a pilot study of their use, and the observed impact of the guidelines on patient care in that facility.

PubMed citation

Free full text

Related Resources From the Same Author(s)

Consumer mobile apps for potential drug–drug interaction check: systematic review and content analysis using the Mobile App Rating Scale (MARS).

April 18, 2018

Patient safety measurement tools used in nursing homes: a systematic literature review.

December 7, 2022

Action research, simulation, team communication, and bringing the tacit into voice. Society for Simulation in Healthcare.

November 18, 2009

Eight human factors and ergonomics principles for healthcare artificial intelligence.

November 2, 2022

Rapid response teams: what's the latest?

March 14, 2018

Effect of prescriber notifications of patient’s fatal overdose on opioid prescribing at 4 to 12 months: a randomized clinical trial.

January 18, 2023

Reducing near miss medication events using an evidence-based approach.

July 27, 2022

Changes in cancer detection and false-positive recall in mammography using artificial intelligence: a retrospective, multireader study.

March 4, 2020

Interventions to engage patients and families in patient safety: a systematic review.

January 20, 2021

Reporting and using near-miss events to improve patient safety in diverse primary care practices: a collaborative approach to learning from our mistakes.

July 29, 2015

Missed breast cancers at US-guided core needle biopsy: how to reduce them.

March 7, 2007

Patient experience must move beyond bad apples.

October 12, 2016

Lehigh Valley Hospital: engaging patients and families.

October 12, 2005

Improving handoffs in the perioperative environment: a conceptual framework of key theories, system factors, methods, and core interventions to ensure success.

July 19, 2023

Retrieval medicine: a review and guide for UK practitioners. Part 2: safety in patient retrieval systems.

December 13, 2006

Diagnostic accuracy of a large language model in pediatric case studies.

January 17, 2024

Overlapping surgery in arthroplasty - a systematic review and meta-analysis.

July 5, 2023

The effect of multidisciplinary care teams on intensive care unit mortality.

March 3, 2010

Status of patient safety culture in community pharmacy settings: a systematic review.

August 23, 2023

Identifying and mapping measures of medication safety during transfer of care in a digital era: a scoping literature review.

December 6, 2023

Incoming interns recognize inadequate physical examination as a cause of patient harm.

July 15, 2020

TeamSTEPPS: an evidence-based approach to reduce clinical errors threatening safety in outpatient settings: an integrative review.

October 3, 2018

Clinical nurse specialists as leaders in rapid response.

March 10, 2010

Controversy and quality improvement: lingering questions about ethics, oversight, and patient safety research.

May 28, 2008

Prevalence, risk factors, and outcomes of idle intravenous catheters: an integrative review.

August 3, 2016

Evaluation of consistency in dosing directions and measuring devices for pediatric nonprescription liquid medications.

December 8, 2010

A method for measuring system safety and latent errors associated with pediatric procedural sedation.

July 27, 2005

A novel approach for assessing bias during team-based clinical decision-making.

June 14, 2023

Making polypharmacy safer for children with medical complexity.

April 5, 2023

Paediatric dosing errors before and after electronic prescribing.

August 18, 2010

Fake and expired medications in simulation-based education: an underappreciated risk to patient safety.

March 23, 2016

EMS non-conveyance: a safe practice to decrease ED crowding or a threat to patient safety?

October 27, 2021

Risk factors of missed colorectal lesions after colonoscopy.

September 6, 2017

Effectiveness of different nursing handover styles for ensuring continuity of information in hospitalised patients.

July 23, 2014

A failure in the medication delivery system-how disclosure and systems investigation improve patient safety.

January 11, 2023

Examining the relationship between nurse fatigue, alertness, and medication errors.

April 3, 2024

Iatrogenic delirium and coma: a "near miss."

May 21, 2008

Patient safety over power hierarchy: a scoping review of healthcare professionals' speaking-up skills training.

June 10, 2020

Liquid medication dosing errors by Hispanic parents: role of health literacy and English proficiency.

May 31, 2017

Work system design for patient safety: the SEIPS model.

October 12, 2011

Analysis of deaths related to anesthesia in the period 1996-2004 from closed claims registered by the Danish Patient Insurance Association.

May 30, 2007

Patient safety culture in assisted living: staff perceptions and association with state regulations.

November 30, 2022

Dispensing errors in community pharmacy: perceived influence of sociotechnical factors.

July 4, 2007

Every error a treasure: improving medication use with a nonpunitive reporting system.

July 18, 2007

Improving communication and response to clinical deterioration to increase patient safety in the intensive care unit.

October 19, 2022

In situ simulation for adoption of new technology to improve sepsis care in rural emergency departments.

June 22, 2022

The gap in electronic drug information resources: a systematic review.

September 12, 2018

Broadening the concept of patient safety culture through value-based healthcare.

August 18, 2021

Racial bias among emergency providers: strategies to mitigate its adverse effects.

May 26, 2021

A piece of my mind. Mistakes.

September 27, 2006

Registered nurses' judgments of the classification and risk level of patient care errors.

October 19, 2011

Clinical clerkship students' perceptions of (un)safe transitions for every patient.

May 14, 2014

Case not closed: prescription errors 12 years after computerized physician order entry implementation.

January 31, 2018

Surgical checklists: a systematic review of impacts and implementation.

September 25, 2013

Relationship of the nursing practice environment with the quality of care and patients' safety in primary health care.

November 29, 2023

Pictograms, units and dosing tools, and parent medication errors: a randomized study.

July 19, 2017

A comparison of medication administration errors from original medication packaging and multi-compartment compliance aids in care homes: a prospective observational study.

June 21, 2017

The role of organizational and professional cultures in medication safety: a scoping review of the literature.

January 15, 2020

Prescribing decision making by medical residents on night shifts: a qualitative study.

November 9, 2022

Using a data-matrix–coded sponge counting system across a surgical practice: impact after 18 months.

February 2, 2011

Liquid medication errors and dosing tools: a randomized controlled experiment.

October 5, 2016

Impact of including readmissions for qualifying events in the Patient Safety Indicators.

April 22, 2015

Nursing home residents with dementia: association between place of death and patient safety culture.

January 20, 2021

Pharmacists' perceptions of computerized prescriber-order-entry systems.

August 8, 2007

Patient and physician perspectives of deprescribing potentially inappropriate medications in older adults with a history of falls: a qualitative study.

May 5, 2021

Prevalence of potentially inappropriate medication use in older adults living in nursing homes: a systematic review.

August 17, 2016

Hospital-acquired SARS-Cov-2 infections in patients: inevitable conditions or medical malpractice?

February 10, 2021

Going to the COVID-19 Gemba: using observation and high reliability strategies to achieve safety in a time of crisis.

June 10, 2020

Monitoring during sedation given by non-anaesthetic doctors.

March 19, 2008

A qualitative analysis of outpatient medication use in community settings: observed safety vulnerabilities and recommendations for improved patient safety.

April 17, 2019

A nursing home’s 64-day Covid siege: ‘They’re all going to die’.

June 24, 2020

Safe practice recommendations for the use of copy-forward with nursing flow sheets in hospital settings.

July 12, 2017

National trends in hospitalizations for opioid poisonings among children and adolescents, 1997 to 2012.

November 16, 2016

Barriers and facilitators to injection safety in ambulatory care settings.

August 29, 2018

Effects of CPOE-based medication ordering on outcomes: an overview of systematic reviews.

July 8, 2020

Hospital checklists are meant to save lives—so why do they often fail?

August 12, 2015

The compliance with a patient safety bundle for management of placenta accreta spectrum.

October 16, 2019

A process for analysis of sentinel events due to health care–associated infection.

November 28, 2007

The dangers of ignoring the Beers criteria—the prescribing cascade.

May 22, 2019

Nurses' perception of error reporting and patient safety culture in Korea.

August 8, 2007

What does it take? A case study of radical change toward patient safety.

March 6, 2005

Development of a checklist of safe discharge practices for hospital patients.

April 24, 2013

Talking about falls: a qualitative exploration of spoken communication of patients' fall risks in hospitals and implications for multifactorial approaches to fall prevention.

November 29, 2023

Human factors in surgery: from Three Mile Island to the operating room.

November 11, 2009

Towards a more patient-centered approach to medication safety.

December 13, 2017

Workarounds to intended use of health information technology: a narrative review of the human factors engineering literature.

May 2, 2018

Workarounds are routinely used by nurses—but are they ethical?

November 8, 2017

Addressing systemic racism in nursing homes: a time for action.

April 14, 2021

The need to include assisted living in responding to the COVID-19 pandemic.

May 20, 2020

Reducing potentially fatal errors associated with high doses of insulin: a successful multifaceted multidisciplinary prevention strategy.

July 6, 2011

Education for the next frontier in patient safety: a longitudinal resident curriculum on diagnostic error.

January 11, 2017

Track, trigger and teamwork: communication of deterioration in acute medical and surgical wards.

January 20, 2010

Setting priorities for patient safety: ethics, accountability, and public engagement.

September 2, 2009

Design of an evidence-based "second victim" curriculum for nurse anesthetists.

June 1, 2016

Detecting patient deterioration using artificial intelligence in a rapid response system.

March 25, 2020

The concept of error and malpractice in radiology.

August 15, 2012

Flexibilization of science, cognitive biases, and the COVID-19 pandemic.

September 23, 2020

A multidisciplinary team approach to retained foreign objects.

March 4, 2009

Evaluation of causes and frequency of medication errors during information technology downtime.

July 8, 2009

Errors in ABO labeling of deceased donor kidneys: case reports and approach to ensuring patient safety.

January 10, 2007

Related Resources

Annual Perspective

Communication During Transitions of Care

March 27, 2024

'Corridor care' in the emergency department: managing patient care in non-clinical areas safely and efficiently.

December 6, 2023

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

Interview

In Conversation with... Susan McGrath, PhD and George Blike, MD about Surveillance Monitoring

April 26, 2023

Perspective

Surveillance Monitoring to Improve Patient Safety in Acute Hospital Care Units

April 26, 2023

Quality improvement initiative to decrease central line-associated bloodstream infections during the COVID-19 pandemic: a "zero harm" approach.

April 19, 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

WebM&M Cases

False Assumptions Result in a Missed Pneumothorax after Bronchoscopy with Transbronchial Biopsy.

October 27, 2022

Strategies to prevent central line-associated bloodstream infections in acute-care hospitals: 2022 Update.

June 22, 2022

Patient handoffs.

June 15, 2022

WebM&M Cases

Check Twice, Transport Once

May 16, 2022

What are we missing? The quality of intraoperative handover before and after introduction of a checklist.

April 6, 2022

From fable to reality at Parkland Hospital: the impact of evidence-based design strategies on patient safety, healing, and satisfaction in an adult inpatient environment.

February 10, 2021

Society for Maternal-Fetal Medicine Special Statement: a maternal transport briefing form and checklist.

December 23, 2020

Annals Clinical Decision Making: avoiding cognitive errors in clinical decision making.

May 20, 2020

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

April 1, 2020

Automation of the I-PASS tool to improve transitions of care.

October 23, 2019

Dynamic pocket card for implementing ISBAR in shift handover communication.

October 23, 2019

Commissioning simulations to test new healthcare facilities: a proactive and innovative approach to healthcare system safety.

September 11, 2019

Is WHO's surgical safety checklist being hyped?

August 21, 2019

Deprescribing Guidelines: Special Section on Symposium Results.

June 26, 2019

Recommendations from a national panel on quality improvement in obstetrics.

April 24, 2019

WebM&M Cases

Adverse Event During Intrahospital Transport

February 1, 2019

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

See More About The Topic

Health Care Providers

Health Care Executives and Administrators

Organizational Behaviorists

Medicine

Nurse Care

Transfer of accountability: transforming shift handover to enhance patient safety.

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

Transfer of accountability: transforming shift handover to enhance patient safety.

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