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Communication between Providers
- Sbar 1
- Communication between Providers 19
- Culture of Safety 3
Education and Training
- Students 1
- Error Reporting and Analysis 12
- Human Factors Engineering 4
- Legal and Policy Approaches 16
- Logistical Approaches 9
- Quality Improvement Strategies 13
- Specialization of Care 3
- Teamwork 2
- Technologic Approaches 12
- Device-related Complications 4
- Diagnostic Errors 9
- Discontinuities, Gaps, and Hand-Off Problems
- Fatigue and Sleep Deprivation 3
- Identification Errors 4
- Medical Complications 6
- Medication Safety 15
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 3
- Surgical Complications 5
- Ambulatory Care 9
- General Hospitals 14
- Long-Term Care 1
- Outpatient Surgery 1
- Patient Transport 1
- Internal Medicine 18
- Nursing 2
- Pharmacy 3
- Family Members and Caregivers 6
- Health Care Executives and Administrators 23
Health Care Providers
- Nurses 5
Non-Health Care Professionals
- Media 1
Search results for "Discontinuities, Gaps, and Hand-Off Problems"
Journal Article > Study
The Ask Me to Explain campaign: a 90-day intervention to promote patient and family involvement in care in a pediatric emergency department.
Tothy AS, Limper HM, Driscoll J, Bittick N, Howell MD. Jt Comm J Qual Patient Saf. 2016;42:281-286.
This study reports on efforts to enhance communication between clinicians and patients in an urban pediatric emergency department. A rapid-change project resulted in significant improvement in patient perceptions of communication—clinicians were perceived as being more sensitive to patients' concerns and displayed better listening behaviors. Poor discharge communication in the emergency department has been linked to safety concerns in prior studies.
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.
Journal Article > Study
The Family Caregiver Activation in Transitions (FCAT) tool: a new measure of family caregiver self-efficacy.
Coleman EA, Ground KL, Maul A. Jt Comm J Qual Patient Saf. 2015;41:502-507.
Efforts to improve patient safety during care transitions have had mixed success, possibly due to failure to effectively engage family and caregivers in the transition process. This study reports on the development and validation of a novel survey instrument that measures family and caregivers' preparation and self-efficacy around supporting patients at the time of hospital discharge.
Journal Article > Study
Family participation during intensive care unit rounds: goals and expectations of parents and health care providers in a tertiary pediatric intensive care unit.
Stickney CA, Ziniel SI, Brett MS, Truog RD. J Pediatr. 2014;165:1245-1251.
In this study, health care providers and parents of children in a pediatric intensive care unit described their perceptions of family involvement in morning rounds. Although parents were overwhelmingly enthusiastic about being included in rounds, providers expressed some concerns and potential drawbacks, such as the avoidance of discussing uncomfortable topics due to presence of family.
Tools/Toolkit > Multi-use Website
Rockville, MD: Agency for Healthcare Research and Quality; June 2013.
Studies have shown that a surprisingly large proportion of hospitalized patients are not aware of their diagnoses or treatment plan and that their preferences are often not taken into account in advanced care planning. This failure to provide patient-centered care indicates a need for increased patient engagement in safety and quality efforts. This toolkit published by the Agency for Healthcare Research and Quality is designed to help hospitals develop partnerships with patients around improving safety. Developed with input from clinicians and patients, the guide emphasizes four strategies—working with patients as advisors, improving bedside communication, integrating patients and families into shift changes, and using patient input to improve the discharge process. An AHRQ WebM&M perspective by Dr. Saul Weingart discusses the practical challenges of engaging patients in improvement efforts.
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.
Journal Article > Commentary
Griffin T. J Perinat Neonatal Nurs. 2010;24:348-353.
This commentary describes nurse change-of-shift reports as a tactic to improve communication with patients and families to promote safe care.
Rockville, MD: Agency for Healthcare Research and Quality. September 29, 2010.
This trio of public service announcements promotes safe medication use, informed discharge, and family and friends as advocates in the hospital.
Tools/Toolkit > Glossary
Chicago, IL: Consumers Advancing Patient Safety; 2009.
This toolkit includes comprehensive information for patients and families to facilitate safe transitions from hospital to follow-up care.
Tools/Toolkit > Government Resource
Leonhardt K, Bonin K, Pagel P. Rockville, MD: Agency for Healthcare Research and Quality; April 2008. AHRQ Publication Nos. 080048.
This AHRQ-funded toolkit outlines how one Midwestern hospital system successfully implemented a patient advisory council. A companion toolkit illustrates how the council worked with the hospital to develop and implement a medication list initiative.
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.
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.
Journal Article > Study
Coleman EA, Parry C, Chalmers S, Min SJ. Arch Intern Med. 2006;166:1822-1828.
Prior studies have documented the safety problems that befall patients with complex illnesses at the time of transition from one setting of care to another. In this trial conducted in an integrated delivery system, patients were randomized to receive usual care or the care transitions intervention at the time of hospital discharge. Intervention patients received a personal health record and a "transition coach," who assisted with continuity of care across settings, arranged home visits after discharge, and helped train patients and caregivers in self-care methods. The foci of the intervention were on ensuring accurate medication usage and appropriate follow-up care. The intervention successfully reduced the likelihood of hospital readmission for 3 months after discharge and appeared to be cost effective.
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.