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Communication between Providers
- Sbar 3
- Communication between Providers 50
- Culture of Safety 6
- Education and Training 10
- Error Reporting and Analysis 18
- Human Factors Engineering 11
- Legal and Policy Approaches 17
- Logistical Approaches 15
- Quality Improvement Strategies 20
- Specialization of Care 3
- Teamwork 6
- Technologic Approaches 21
- Alert fatigue 1
- Device-related Complications 7
- Diagnostic Errors 14
- Discontinuities, Gaps, and Hand-Off Problems
- Fatigue and Sleep Deprivation 3
- Identification Errors 6
- Interruptions and distractions 1
- Medical Complications 8
- Medication Errors/Preventable Adverse Drug Events 15
- Nonsurgical Procedural Complications 2
- Psychological and Social Complications 2
- Surgical Complications 8
- Ambulatory Care 13
- General Hospitals 20
- Long-Term Care 2
- Outpatient Surgery 2
- Patient Transport 3
- Internal Medicine 26
- Nursing 7
- Pharmacy 15
- Family Members and Caregivers 2
- Health Care Executives and Administrators 58
Health Care Providers
- Nurses 9
- Physicians 10
Non-Health Care Professionals
- Media 1
- Patients 48
Search results for "Discontinuities, Gaps, and Hand-Off Problems"
- Newspaper/Magazine Article
- Discontinuities, Gaps, and Hand-Off Problems
Butcher L. Managed Care. June 2019;28:37-39.
Inconsistent patient name entry practices in electronic health records can contribute to wrong-patient errors. This magazine article reports on the complex nature of addressing patient-matching discrepancies as an economic, privacy, and technical problem. Improvement strategies include the development and adoption of a national identification program and biometric technology. A WebM&M commentary discussed problems associated with name similarities in the electronic patient record.
Peeples L. Pharmacy Practice News. October 10, 2018.
Structured handoffs can reduce communication problems that contribute to medical error. This magazine article reports on how I-PASS implementation can help enhance the quality and completeness of handoffs, highlights the need for pharmacists to be more engaged in handoff improvement, and offers insights for enhancing their role in the process. In a past PSNet interview, Dr. Amy Starmer discussed the implementation and findings of the landmark I-PASS study.
Ready T. HealthLeaders Media. September 26, 2017.
Transitions are an error-prone process. This news article reports that organizational leadership should be engaged in enhancing safety of transitions and facilitating design of sustainable improvements. The article also highlights successful interventions that have benefited from leadership engagement, such as the I-PASS program.
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.
Clements K. Nurs Manage. 2017;48:12-13.
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.
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.
Quick Safety. November 30, 2015;(18):1-3.
Landro L. Wall Street Journal. October. 26, 2015.
ISMP Medication Safey Alert! Acute Care Edition. March 7, 2013;18:1-3.
This newsletter article details the characteristics of successful community liaison programs, which facilitate transitions from hospital to home, and describes how such programs can reduce the risk of medication discrepancies.
Shannon DW, Myers LA. Patient Saf Qual Healthc. September/October 2012;9:20-22,24-26.
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.
Dyell D. Patient Saf Qual Healthc. January/February 2012;9:34-37.
This magazine article describes problems with medical devices and recommends that device connectivity and integration can improve safety.
Landro L. Wall Street Journal. June 7, 2011:D3.
Butterfield S, Stegel C, Glock S, Tartaglia D. Patient Saf Qual Healthc. May/June 2011;8:29-33.
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.
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.
Sower VE, Duffy JA, Kohers G. American Society for Quality. August 2008.
This article describes the application of Formula One pit stop techniques to improving hand-off systems within a health care setting in the context of one British hospital's research on teamwork in Formula One pit crews.
Runy LA. Hosp Health Netw. 2008 May;82:7p following 40, 2.
This article highlights several techniques to improve the safety of patient transfers. Examples of such tools are included along with case studies of their application.
ISMP Medication Safety Alert! Acute Care Edition. August 23, 2007;12:1-3.
This article discusses the myriad dosing methods that can lead to errors in administering intravenous medications and programming infusion pumps.