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PA-PSRS Patient Saf Advis. March 2009;6:16-19.
This article discusses strategies to ensure safe transitions for patients between hospital departments. These strategies include transport team development, use of standardized communication tools, and educational programming for unlicensed health care personnel.
Special or Theme Issue
FIRST Do No Harm. December 2012;1-8.
This newsletter issue highlights initiatives and tools developed to improve handoff communication in Massachusetts.
Journal Article > Study
Defining minimum necessary anticoagulation-related communication at discharge: Consensus of the Care Transitions Task Force of the New York State Anticoagulation Coalition.
Triller D, Myrka A, Gassler J, et al. Jt Comm J Qual Patient Saf. 2018;44:630-640.
Patients prescribed high-risk medications, including anticoagulants, are at increased risk for adverse drug events and may be particularly vulnerable during care transitions. This study describes how a multidisciplinary panel of anticoagulation experts used an iterative consensus-building process to determine what information should be communicated to relevant providers for all patients on anticoagulation undergoing a transition in care.
Cierniak KH, Gaunt MJ, Grissinger M. PA-PSRS. Patient Saf Advis. 2018;15(4).
The operating room environment harbors particular patient safety hazards. Drawing from 1137 perioperative medication error reports submitted over a 1-year period, this analysis found that more than half of the recorded incidents reached the patient and the majority of those stemmed from communication breakdowns during transitions or handoffs. The authors provide recommendations to reduce risks of error, including using barcode medication administration, standardizing handoff procedures, and stocking prefilled syringes.