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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.
Hamilton WL. Patient Saf Qual Healthc. July 31, 2017.
Miscommunication during care transitions can contribute to medical errors. This article discusses how handoff communication tools can help to improve reliability of information transfer associated with anesthesia practice. The authors emphasize the importance of standardizing the process of perioperative data collection.
Khullar D. New York Times. March 17, 2016.
Preventing readmissions after hospital discharge is a national policy priority. This newspaper article discusses how poor communication between hospital-based and outpatient physicians, lack of involvement of the frontline care team in the discharge process, and production pressures can diminish the safety of discharge. The piece also describes strategies to enhance transitions and reduce readmission rates.
Agency for Healthcare Research and Quality. Research Activities. May 2013:1, 3-4.
This newsletter article describes the development of the Medications at Transitions and Clinical Handoffs (MATCH) toolkit and relates one hospital's experience implementing it.
Crocker C. Nurs Times. 2009 Nov 24;105:12-15.
This article tracks the care of a United Kingdom National Health Service patient and identifies several areas for process improvement to ensure safe medication delivery.