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- Communication Improvement
- Culture of Safety 2
- Education and Training 3
- Error Reporting and Analysis 1
- Human Factors Engineering 5
- Legal and Policy Approaches 2
- Quality Improvement Strategies 3
- Specialization of Care 1
- Teamwork 2
- Technologic Approaches 5
- Device-related Complications 2
- Discontinuities, Gaps, and Hand-Off Problems 20
- Medication Safety 6
- Psychological and Social Complications 1
- Surgical Complications 1
- Medicine 16
- Nursing 3
- Pharmacy 2
- Health Care Executives and Administrators 16
Health Care Providers
- Nurses 2
- Non-Health Care Professionals 6
- Patients 5
Search results for "Structured Hand-offs"
- Newspaper/Magazine Article
- Structured Hand-offs
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.
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.
Landro L. Wall Street Journal. October. 26, 2015.
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.
ISMP Medication Safety Alert! Acute Care Edition. July 3, 2008;13:1-3.
This article reports on the potentially fatal error of administering epidural medications intravenously and provides guidelines to safeguard against such epidural–IV route mix-ups.
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.
Naik G. Wall Street Journal. November 14, 2006:A1. [reprinted on Post-gazette.com].
This story describes how hospitals in the United Kingdom have incorporated teamwork principles used by auto racing pit crews to improve patient safety during handoffs.
Gulati G. Saferhealthcare. July 4, 2006.
The investigators asked National Health Service consultants and house officers what they would consider an ideal handoff in psychiatric care. They found that practitioners preferred written and/or face-to-face handoffs.
Landro L. Wall Street Journal (Eastern edition). June 28, 2006:D1. [reprinted on Post-gazette.com].
This article reports on communication interventions such as SBAR (Situation-Background-Assessment-Recommendation) that make patient hand-offs more reliable.
Liberatore K. PA-PSRS Patient Saf Advis. 2018 March;15.
Latex products are widely available in hospitals and represent a persistent threat to patients with latex allergies. Drawing from 616 reported latex-related events, this investigation found that more than half of the incidents were associated with indwelling urinary catheter use. Tracking staff awareness of latex allergies, purchasing latex-safe alternatives, and improving handoff documentation of patient allergies are possible risk reduction strategies. A WebM&M commentary discussed allergy documentation in patient health records.
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.
Alderman L. New York Times. June 18, 2010;B6.
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.