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Cases & Commentaries
- Web M&M
Eugene Litvak, PhD, and Sarah A. Bernheim; November 2011
Following hospitalization for suicidality, a woman was discharged to the care of her outpatient psychiatrist, a senior resident who was about to graduate. At her last visit in June before the year-end transfer, the patient was unable to schedule a follow-up visit because the new residents' schedules were not yet in the system. The delay in care had deadly consequences.
Thompson D, Holzmueller C, Hunt D, Cafe C, Sexton B, Pronovost PJ. Jt Comm J Qual Patient Saf. 2005;31:476-479.
The authors describe a tool to support reliable communication at shift change and promote improved patient safety. The project was supported by the Agency for Healthcare Research and Quality (AHRQ).
Kingston, ACT, Australia: Australian Medical Association; 2006.
This report outlines best practices for patient transfer and shares experiences from the field for Australian physicians and health care organizations that seek to improve their handoff processes.
Journal Article > Study
Estryn-Behar MR, Milanini-Magny G, Chaumon E, et al. J Patient Saf. 2014;10:29-44.
This direct observation study found that registered nurses, physicians, and nursing aides have frequent interruptions and limited time for shift-change handoffs. This finding suggests that widespread efforts to ensure adequate handoff time and minimize interruptions have not mitigated these problems in hospital settings.