Narrow Results Clear All
- Communication Improvement 6
- Culture of Safety 1
Education and Training
- Students 1
- Error Reporting and Analysis 1
- Legal and Policy Approaches 1
- Logistical Approaches 1
- Teamwork 1
- Clinical Information Systems
- Device-related Complications 1
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems
- Identification Errors 1
- Medication Safety 3
- Surgical Complications 1
Search results for "Discontinuities, Gaps, and Hand-Off Problems"
Landro L. Wall Street Journal. June 7, 2011:D3.
Grant > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; June 2008.
This announcement describes the 19 projects funded by the Agency for Healthcare Research and Quality in 2006 that studies the potential of simulation to improve patient safety.
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.
Rifkin D. New York Times. November 16, 2009;Science Desk:5.
Reporting on cases of miscommunication and missed diagnosis, this news column illustrates how strictly following quality improvement procedures might lead providers to ignore important contextual information—from patients—that also contributes to safe care.
Cooney E. Worcester Telegram & Gazette. January 28, 2008;Living section:E1.
This article discusses an AHRQ-funded program to study information technology tools and their ability to minimize medication errors in a geriatric patient population.
Paterson R. Auckland, New Zealand: Office of the Health and Disability Commissioner; April 24, 2007.
This report analyzes an incident of medication error that led to a patient's death, discusses the subsequent actions taken by the health board, and calls for a coordinated approach to medication reconciliation in New Zealand.
Brown D. Washington Post. April 10, 2007:HE01.
This article describes the Veterans Affairs' universal medical records network and illustrates how use of electronic medical records at VA medical centers supports safe care.
Urbina I, Nixon R. New York Times. March 30, 2007;National Desk section:1.
This article reports on the inconsistent use of the Department of Defense electronic medical records system and how this has led to medical errors and delays in care for US veterans.
Landro L. Wall Street Journal (Eastern edition). November 29, 2006: D1-D5. [Reprinted on Post-gazette.com].
This article describes a decision support program used by Kaiser Permanente and U.S. Veterans Administration to help minimize misdiagnosis.
Cases & Commentaries
- Web M&M
Russ Cucina, MD, MS; July 2006
Despite full documentation and a wristband regarding her severe food allergy, an inpatient is advertently fed eggs and suffers an allergic reaction.