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Communication between Providers
- Sbar 1
- Communication between Providers 15
- Culture of Safety 2
- Education and Training 5
- Error Reporting and Analysis 11
- Human Factors Engineering 3
- Legal and Policy Approaches 14
- Logistical Approaches 9
- Quality Improvement Strategies 10
- Specialization of Care 2
- Technologic Approaches 10
- Device-related Complications 3
- Diagnostic Errors 9
- Discontinuities, Gaps, and Hand-Off Problems
- Fatigue and Sleep Deprivation 3
- Identification Errors 4
- Medical Complications 6
- Medication Safety 10
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 1
- Surgical Complications 5
- Internal Medicine 14
- Nursing 1
- Pharmacy 2
- Health Care Executives and Administrators 19
Health Care Providers
- Nurses 2
Non-Health Care Professionals
- Media 1
Search results for "Discontinuities, Gaps, and Hand-Off Problems"
Rau J. Washington Post. April 29, 2016.
Transitions in care between inpatient and outpatient settings are an increasing concern for patient safety. Reporting on a fatal medication error that was missed by a patient's pharmacist and home health nurses, this newspaper article discusses various risks associated with hospital-to-home transitions such as insufficient case management and communication.
Landro L. Wall Street Journal. October. 26, 2015.
Lord T. Patient Saf Qual Healthc. March/April 2012;9:38-41,44.
This article details how miscommunication and lack of patient-centered care contributed to errors that led to the death of a child.
Landro L. Wall Street Journal. June 7, 2011:D3.
Parikh R. Los Angeles Times. April 18, 2011.
This newspaper article describes how structured communication techniques borrowed from other fields could improve handoffs in health care.
Kowalczyk L. Boston Globe. April 21, 2007:B1.
This article reports on the results from Joint Commission site inspections of five Boston-area hospitals.
Landro L. Wall Street Journal. April 4, 2007:D5.
This article reports on initiatives to standardize the color designations of color-coded wristbands to avoid confusion and reduce the risk of error.
Kowalczyk L. Boston Globe. July 29, 2017.
Aleccia J. Seattle Times. June 18, 2016.
Patients who experience harm while receiving medical care can serve as powerful advocates for patient safety. This news article reports on a patient who became engaged in working to redesign processes to improve patient safety after he became paralyzed from the chest down due to a cascade of communication errors.
Bond A. New York Times. June 16, 2015.
Clinician communication with patients and families during transitions has been a focus of safety improvement efforts. This newspaper article describes insights from a resident physician regarding how poor communication between teams caring for patients can result in unnecessary care, family discomfort, and confusion for the patient receiving different information among varying teams.
Gabler E. Milwaukee Journal Sentinel. May 15, 2015.
Reporting on weaknesses in laboratory testing methods, this news article discusses patients' experiences with testing errors to illustrate how such failures can contribute to patient harm—such as missed or delayed diagnosis—and raises concerns about insufficient transparency, investigations, and regulations around laboratory facilities with poor processes.
LaFraniere S. New York Times. April 19, 2015.
Reporting on a case involving an overlooked test result that contributed to the death of a patient in the military medical system, this newspaper article highlights how insufficient transparency can prevent patients and their families from learning about what happened during their care and hinder opportunities to recognize processes in need of improvement.
Gubar S. New York Times. October 30, 2014.
This newspaper article describes how surgical complications, health care–associated infections, and ineffective patient–provider communication contributed to a patient's experience with harm and suggests that transparency around the incident and preoperative patient briefings could have improved the situation.
Flatten M. Washington Examiner. August 18–22, 2014.
Lerner M. Star Tribune. October 11, 2012.
This newspaper article reports on how transition coaches can help improve transfer and discharge communication to prevent readmissions.
Hartocollis A. New York Times. July 28, 2012.
This newspaper article reports on the missteps that contributed to the death of a young woman after she was hospitalized in an incident reminiscent of Libby Zion.
Dwyer J. New York Times. July 11, 2012:A15.
This newspaper article reports on gaps in communication and a missed sepsis diagnosis that led to a patient's death.
Eban K. Self Magazine. November 2011.
This magazine article reports on cases in which outsourcing the interpretation of radiology tests contributed to patient harm.
Hamill SD. Pittsburgh Post-Gazette. July 10, 2011:A6.
This newspaper article reports how a missed test result alert led to a disease-free transplant patient being infected with hepatitis.
Alderman L. New York Times. June 18, 2010;B6.