Study Gaps in pediatric clinician communication and opportunities for improvement. Citation Text: Woods D, Holl JL, Angst DB, et al. Gaps in pediatric clinician communication and opportunities for improvement. J Healthc Qual. 2008;30(5):43-54. Copy Citation Format: Google ScholarPubMedBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL October 22, 2008 Woods D, Holl JL, Angst DB, et al. J Healthc Qual. 2008;30(5):43-54. View more articles from the same authors. This study used focus groups to explore problems in clinician-to-clinician communication among pediatricians. Participants noted significant organizational and system barriers to effective communication, resulting in impaired patient safety. PubMed citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Cite Citation Citation Text: Woods D, Holl JL, Angst DB, et al. Gaps in pediatric clinician communication and opportunities for improvement. J Healthc Qual. 2008;30(5):43-54. Copy Citation Format: Google ScholarPubMedBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Related Resources From the Same Author(s) Ambulatory care adverse events and preventable adverse events leading to a hospital admission. April 18, 2007 Errors and the burden of errors: attitudes, perceptions, and the culture of safety in pediatric cardiac surgical teams. April 30, 2008 Observation for assessment of clinician performance: a narrative review. November 11, 2015 A randomized trial of a multifactorial strategy to prevent serious fall injuries. July 29, 2020 High-alert medications in the pediatric intensive care unit. January 7, 2009 Patient safety problems in adolescent medical care. January 18, 2006 Adverse events and preventable adverse events in children. March 6, 2005 Minimizing Opioid Prescribing in Surgery (MOPiS) initiative: an analysis of implementation barriers. April 17, 2019 Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical centers, April-June 2020. September 23, 2020 Optimizing Pediatric Patient Safety in the Emergency Care Setting. October 19, 2022 Families as partners in hospital error and adverse event surveillance. March 8, 2017 Anatomy of a patient safety event: a pediatric patient safety taxonomy. December 21, 2005 Association of diagnostic stewardship for blood cultures in critically ill children with culture rates, antibiotic use, and patient outcomes: results of the Bright STAR Collaborative. May 18, 2022 Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010–2011. May 25, 2016 Association between surgeon technical skills and patient outcomes. September 9, 2020 Association between hospital safety culture and surgical outcomes in a statewide surgical quality improvement collaborative. May 15, 2019 Prevalence of Errors in Anaphylaxis in Kids (PEAK): a multicenter simulation-based study. July 22, 2020 Transitions of Care Consensus Policy Statement American College of Physicians-Society of General Internal Medicine-Society of Hospital Medicine-American Geriatrics Society-American College of Emergency Physicians-Society of Academic Emergency Medicine. April 22, 2009 Admission handoff communications: clinician's shared understanding of patient severity of illness and problems. November 25, 2009 Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions. August 4, 2021 Advancing the science of patient safety. May 25, 2011 The top patient safety strategies that can be encouraged for adoption now. March 13, 2013 Sequential implementation of the EQUIPPED geriatric medication safety program as a learning health system. September 9, 2020 Early prescribing outcomes after exporting the EQUIPPED medication safety improvement programme. January 19, 2022 Prevalence and causes of diagnostic errors in hospitalized patients under investigation for COVID-19. April 12, 2023 How active resisters and organizational constipators affect health care–acquired infection prevention efforts. April 13, 2011 The importance of leadership in preventing healthcare–associated infection: results of a multisite qualitative study. September 15, 2010 The 2017 ACGME common work hour standards: promoting physician learning and professional development in a safe, humane environment. January 31, 2018 Comparative performance of pediatric weight estimation techniques: a human factor errors analysis. November 1, 2017 ACR guidance document on MR safe practices: 2013. March 21, 2013 Effect of pharmacist counseling intervention on health care utilization following hospital discharge: a randomized control trial. June 8, 2016 Rate of sepsis hospitalizations after misdiagnosis in adult emergency department patients: a look-forward analysis with administrative claims data using Symptom-Disease Pair Analysis of Diagnostic Error methodology in an integrated health system. May 12, 2021 Antecedent treat-and-release diagnoses prior to sepsis hospitalization among adult emergency department patients: a look-back analysis employing insurance claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology. December 8, 2021 Evaluating shared decision making for lung cancer screening. September 5, 2018 Pilot testing of a model for insurer-driven, large-scale multicenter simulation training for operating room teams. December 11, 2013 Physicians' perspectives regarding prescription drug monitoring program use within the Department of Veterans Affairs: a multi-state qualitative study. April 18, 2018 Evaluation of clinical practice guidelines on fall prevention and management for older adults: a systematic review. January 12, 2022 Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study. November 16, 2022 Physician and nurse well-being and preferred interventions to address burnout in hospital practice: factors associated with turnover, outcomes, and patient safety. July 19, 2023 Adopting real-time surveillance dashboards as a component of an enterprisewide medication safety strategy. January 30, 2005 The Pursuing Excellence Collaborative: engaging first-year residents and fellows in patient safety event investigations. August 30, 2023 Explanation and elaboration of the SQUIRE (Standards for Quality Improvement Reporting Excellence) Guidelines, V.2.0: examples of SQUIRE elements in the healthcare improvement literature. May 25, 2016 Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016 March 3, 2017 Isolation precautions for visitors. April 29, 2015 Changes in medical errors after implementation of a handoff program. November 12, 2014 Readiness of US general surgery residents for independent practice. October 4, 2017 Improving handoffs in the emergency department. October 28, 2009 An institution-wide handoff task force to standardise and improve physician handoffs. June 27, 2012 Patient concerns about medical errors in emergency departments. March 6, 2005 The impact of racism on child and adolescent health. July 1, 2019 An anesthesia preinduction checklist to improve information exchange, knowledge of critical information, perception of safety, and possibly perception of teamwork in anesthesia teams. May 6, 2015 Evaluation of the association between Nursing Home Survey on Patient Safety culture (NHSOPS) measures and catheter-associated urinary tract infections: results of a national collaborative. October 18, 2017 Peer feedback, learning, and improvement: answering the call of the Institute of Medicine report on diagnostic error. December 7, 2016 Uncovering system errors using a rapid response team: cross-coverage caught in the crossfire. July 29, 2009 Changes in prevalence of health care-associated infections in U.S. hospitals. November 14, 2018 Surgical training, duty-hour restrictions, and implications for meeting the Accreditation Council for Graduate Medical Education core competencies: views of surgical interns compared with program directors. July 11, 2012 Optimizing Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older Adults (OPERAM): cluster randomised controlled trial. August 18, 2021 Preventing home medication administration errors. March 14, 2022 The impact of prescribing safety alerts for elderly persons in an electronic medical record: an interrupted time series evaluation. May 31, 2006 Hospital-wide cardiac arrest in situ simulation to identify and mitigate latent safety threats. June 8, 2022 Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator for Postoperative Respiratory Failure (PSI 11) does not identify accurately patients who received unsafe care. November 16, 2016 A cluster randomized trial of two implementation strategies to deliver audit and feedback in the EQUIPPED medication safety program. April 26, 2023 Designing a safer radiology department. March 29, 2012 Incidence and trends of sepsis in US hospitals using clinical vs claims data, 2009--2014. September 27, 2017 How safe are paediatric emergency departments? A national prospective cohort study. August 3, 2022 Effect of a protected sleep period on hours slept during extended overnight in-hospital duty hours among medical interns: a randomized trial. December 12, 2012 A framework for evaluating the appropriateness of clinical decision support alerts and responses. September 21, 2011 Evidence-based guidelines for fatigue risk management in EMS: formulating research questions and selecting outcomes. December 7, 2016 Creating a better discharge summary: improvement in quality and timeliness using an electronic discharge summary. May 6, 2009 Applying Lean Sigma solutions to mistake-proof the chemotherapy preparation process. February 17, 2010 Transforming communication and safety culture in intrapartum care: a multi-organization blueprint. June 3, 2015 Complexity and challenges of the clinical diagnosis and management of Long COVID. November 30, 2022 Association between implementing comprehensive learning collaborative strategies in a statewide collaborative and changes in hospital safety culture. September 2, 2020 Health care safety during the pandemic and beyond--building a system that ensures resilience. February 23, 2022 User-centered collaborative design and development of an inpatient safety dashboard. September 20, 2017 Clinical pathway adherence and missed diagnostic opportunities among children with musculoskeletal infections. September 6, 2023 Potential medication dosing errors in outpatient pediatrics. January 11, 2006 Risk assessment of the acute stroke diagnostic process using failure modes, effects, and criticality analysis. March 1, 2023 Operating room to intensive care unit handoffs and the risks of patient harm. July 22, 2015 Comparing catheter-associated urinary tract infection prevention programs between Veterans Affairs nursing homes and non–Veterans Affairs nursing homes. April 5, 2017 Promoting patient safety through prospective risk identification: example from peri-operative care. March 17, 2010 Effect of complementary interventions to redesign care on teamwork and quality for hospitalized medical patients: a pragmatic controlled trial. November 15, 2023 Contextual factors influencing the implementation of a multifaceted intervention to improve teamwork and quality for hospitalized patients: a multi-site qualitative comparative case study. November 1, 2023 Effect of patient- and medication-related factors on inpatient medication reconciliation errors. March 7, 2012 Electronic handoff instruments: a truly multidisciplinary tool? April 9, 2014 Education outcomes from a duty-hour flexibility trial in internal medicine. March 28, 2018 Patient Safety Innovations Handshake antimicrobial stewardship as a model to recognize and prevent diagnostic errors September 29, 2021 Handshake antimicrobial stewardship as a model to recognize and prevent diagnostic errors. September 8, 2021 The use of technology for urgent clinician to clinician communications: a systematic review of the literature. January 7, 2015 Failure mode and effects analysis: a comparison of two common risk prioritisation methods. May 4, 2016 The role of technology in clinician-to-clinician communication. August 14, 2013 Relationship between state malpractice environment and quality of health care in the United States. April 12, 2017 Do safety culture scores in nursing homes depend on job role and ownership? Results from a national survey. October 4, 2017 Relationship between preventability of death after coronary artery bypass graft surgery and all-cause risk-adjusted mortality rates. July 9, 2008 The role of housestaff in implementing medication reconciliation on admission at an academic medical center. June 16, 2010 Use of artificial intelligence for image analysis in breast cancer screening programmes: systematic review of test accuracy. November 17, 2021 Types, prevalence, and potential clinical significance of medication administration errors in assisted living. June 4, 2008 Team debriefing in the COVID-19 pandemic: a qualitative study of a hospital-wide clinical event debriefing program and a novel qualitative model to analyze debriefing content. November 16, 2022 Nurse well-being: a concept analysis. August 17, 2022 Outcomes of concurrent operations: results from the American College of Surgeons' National Surgical Quality Improvement Program. October 11, 2017 View More Related Resources Annual Perspective Communication During Transitions of Care March 27, 2024 Interview In Conversation with... Kathleen Sanford and Sue Schuelke about Virtual Nursing August 30, 2023 Perspectives on Safety Virtual Nursing: Improving Patient Care and Meeting Workforce Challenges August 30, 2023 Improving standardization of paging communication using quality improvement methodology. April 10, 2019 Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors. October 24, 2018 Effect of a pediatric early warning system on all-cause mortality in hospitalized pediatric patients. March 7, 2018 Improving communication with primary care physicians at the time of hospital discharge. February 8, 2017 Reliability of verbal handoff assessment and handoff quality before and after implementation of a resident handoff bundle. June 22, 2016 Why July matters. May 11, 2016 Why do we still page each other? Examining the frequency, types and senders of pages in academic medical services. February 3, 2016 A step toward high reliability: implementation of a daily safety brief in a children's hospital. September 24, 2014 Project BOOST implementation: lessons learned. September 10, 2014 The influence of organizational factors on patient safety: examining successful handoffs in health care. August 27, 2014 Physician attitudes toward family-activated medical emergency teams for hospitalized children. April 2, 2014 Implementation of a pediatric rapid response team: experience of the Hospital for Sick Children in Toronto. March 12, 2014 Assigning a team-based pager for on-call physicians reduces paging errors in a large academic hospital. February 12, 2014 Sign-out snapshot: cross-sectional evaluation of written sign-outs among specialties. January 15, 2014 Improvement of medication event interventions through use of an electronic database. December 18, 2013 Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. December 11, 2013 Impact of an automated email notification system for results of tests pending at discharge: a cluster-randomized controlled trial. November 27, 2013 An intervention model that promotes accountability: peer messengers and patient/family complaints. October 9, 2013 Principles supporting dynamic clinical care teams: an American College of Physicians position paper. September 25, 2013 'You talking to me?' Docs and feedback. September 18, 2013 "Excuse me": teaching interns to speak up. August 28, 2013 Rapid response teams: qualitative analysis of their effectiveness. June 19, 2013 What do patients think about year-end resident continuity clinic handoffs?: a qualitative study. May 22, 2013 Effect of a systems intervention on the quality and safety of patient handoffs in an internal medicine residency program. May 15, 2013 Development of a checklist of safe discharge practices for hospital patients. April 24, 2013 Hospital-initiated transitional care interventions as a patient safety strategy: a systematic review. March 20, 2013 Handovers from the OR to the ICU. January 23, 2013 View More See More About The Topic Hospitals Physicians Health Care Executives and Administrators General Internal Medicine Hospital Medicine View More
Ambulatory care adverse events and preventable adverse events leading to a hospital admission. April 18, 2007
Errors and the burden of errors: attitudes, perceptions, and the culture of safety in pediatric cardiac surgical teams. April 30, 2008
Minimizing Opioid Prescribing in Surgery (MOPiS) initiative: an analysis of implementation barriers. April 17, 2019
Seroprevalence of SARS-CoV-2 among frontline health care personnel in a multistate hospital network--13 academic medical centers, April-June 2020. September 23, 2020
Association of diagnostic stewardship for blood cultures in critically ill children with culture rates, antibiotic use, and patient outcomes: results of the Bright STAR Collaborative. May 18, 2022
Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010–2011. May 25, 2016
Association between hospital safety culture and surgical outcomes in a statewide surgical quality improvement collaborative. May 15, 2019
Prevalence of Errors in Anaphylaxis in Kids (PEAK): a multicenter simulation-based study. July 22, 2020
Transitions of Care Consensus Policy Statement American College of Physicians-Society of General Internal Medicine-Society of Hospital Medicine-American Geriatrics Society-American College of Emergency Physicians-Society of Academic Emergency Medicine. April 22, 2009
Admission handoff communications: clinician's shared understanding of patient severity of illness and problems. November 25, 2009
Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions. August 4, 2021
Sequential implementation of the EQUIPPED geriatric medication safety program as a learning health system. September 9, 2020
Early prescribing outcomes after exporting the EQUIPPED medication safety improvement programme. January 19, 2022
Prevalence and causes of diagnostic errors in hospitalized patients under investigation for COVID-19. April 12, 2023
How active resisters and organizational constipators affect health care–acquired infection prevention efforts. April 13, 2011
The importance of leadership in preventing healthcare–associated infection: results of a multisite qualitative study. September 15, 2010
The 2017 ACGME common work hour standards: promoting physician learning and professional development in a safe, humane environment. January 31, 2018
Comparative performance of pediatric weight estimation techniques: a human factor errors analysis. November 1, 2017
Effect of pharmacist counseling intervention on health care utilization following hospital discharge: a randomized control trial. June 8, 2016
Rate of sepsis hospitalizations after misdiagnosis in adult emergency department patients: a look-forward analysis with administrative claims data using Symptom-Disease Pair Analysis of Diagnostic Error methodology in an integrated health system. May 12, 2021
Antecedent treat-and-release diagnoses prior to sepsis hospitalization among adult emergency department patients: a look-back analysis employing insurance claims data using Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) methodology. December 8, 2021
Pilot testing of a model for insurer-driven, large-scale multicenter simulation training for operating room teams. December 11, 2013
Physicians' perspectives regarding prescription drug monitoring program use within the Department of Veterans Affairs: a multi-state qualitative study. April 18, 2018
Evaluation of clinical practice guidelines on fall prevention and management for older adults: a systematic review. January 12, 2022
Implementation of the I-PASS handoff program in diverse clinical environments: a multicenter prospective effectiveness implementation study. November 16, 2022
Physician and nurse well-being and preferred interventions to address burnout in hospital practice: factors associated with turnover, outcomes, and patient safety. July 19, 2023
Adopting real-time surveillance dashboards as a component of an enterprisewide medication safety strategy. January 30, 2005
The Pursuing Excellence Collaborative: engaging first-year residents and fellows in patient safety event investigations. August 30, 2023
Explanation and elaboration of the SQUIRE (Standards for Quality Improvement Reporting Excellence) Guidelines, V.2.0: examples of SQUIRE elements in the healthcare improvement literature. May 25, 2016
Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock: 2016 March 3, 2017
An anesthesia preinduction checklist to improve information exchange, knowledge of critical information, perception of safety, and possibly perception of teamwork in anesthesia teams. May 6, 2015
Evaluation of the association between Nursing Home Survey on Patient Safety culture (NHSOPS) measures and catheter-associated urinary tract infections: results of a national collaborative. October 18, 2017
Peer feedback, learning, and improvement: answering the call of the Institute of Medicine report on diagnostic error. December 7, 2016
Uncovering system errors using a rapid response team: cross-coverage caught in the crossfire. July 29, 2009
Surgical training, duty-hour restrictions, and implications for meeting the Accreditation Council for Graduate Medical Education core competencies: views of surgical interns compared with program directors. July 11, 2012
Optimizing Therapy to Prevent Avoidable Hospital Admissions in Multimorbid Older Adults (OPERAM): cluster randomised controlled trial. August 18, 2021
The impact of prescribing safety alerts for elderly persons in an electronic medical record: an interrupted time series evaluation. May 31, 2006
Hospital-wide cardiac arrest in situ simulation to identify and mitigate latent safety threats. June 8, 2022
Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicator for Postoperative Respiratory Failure (PSI 11) does not identify accurately patients who received unsafe care. November 16, 2016
A cluster randomized trial of two implementation strategies to deliver audit and feedback in the EQUIPPED medication safety program. April 26, 2023
Incidence and trends of sepsis in US hospitals using clinical vs claims data, 2009--2014. September 27, 2017
Effect of a protected sleep period on hours slept during extended overnight in-hospital duty hours among medical interns: a randomized trial. December 12, 2012
A framework for evaluating the appropriateness of clinical decision support alerts and responses. September 21, 2011
Evidence-based guidelines for fatigue risk management in EMS: formulating research questions and selecting outcomes. December 7, 2016
Creating a better discharge summary: improvement in quality and timeliness using an electronic discharge summary. May 6, 2009
Applying Lean Sigma solutions to mistake-proof the chemotherapy preparation process. February 17, 2010
Transforming communication and safety culture in intrapartum care: a multi-organization blueprint. June 3, 2015
Association between implementing comprehensive learning collaborative strategies in a statewide collaborative and changes in hospital safety culture. September 2, 2020
Health care safety during the pandemic and beyond--building a system that ensures resilience. February 23, 2022
User-centered collaborative design and development of an inpatient safety dashboard. September 20, 2017
Clinical pathway adherence and missed diagnostic opportunities among children with musculoskeletal infections. September 6, 2023
Risk assessment of the acute stroke diagnostic process using failure modes, effects, and criticality analysis. March 1, 2023
Comparing catheter-associated urinary tract infection prevention programs between Veterans Affairs nursing homes and non–Veterans Affairs nursing homes. April 5, 2017
Promoting patient safety through prospective risk identification: example from peri-operative care. March 17, 2010
Effect of complementary interventions to redesign care on teamwork and quality for hospitalized medical patients: a pragmatic controlled trial. November 15, 2023
Contextual factors influencing the implementation of a multifaceted intervention to improve teamwork and quality for hospitalized patients: a multi-site qualitative comparative case study. November 1, 2023
Effect of patient- and medication-related factors on inpatient medication reconciliation errors. March 7, 2012
Patient Safety Innovations Handshake antimicrobial stewardship as a model to recognize and prevent diagnostic errors September 29, 2021
Handshake antimicrobial stewardship as a model to recognize and prevent diagnostic errors. September 8, 2021
The use of technology for urgent clinician to clinician communications: a systematic review of the literature. January 7, 2015
Failure mode and effects analysis: a comparison of two common risk prioritisation methods. May 4, 2016
Relationship between state malpractice environment and quality of health care in the United States. April 12, 2017
Do safety culture scores in nursing homes depend on job role and ownership? Results from a national survey. October 4, 2017
Relationship between preventability of death after coronary artery bypass graft surgery and all-cause risk-adjusted mortality rates. July 9, 2008
The role of housestaff in implementing medication reconciliation on admission at an academic medical center. June 16, 2010
Use of artificial intelligence for image analysis in breast cancer screening programmes: systematic review of test accuracy. November 17, 2021
Types, prevalence, and potential clinical significance of medication administration errors in assisted living. June 4, 2008
Team debriefing in the COVID-19 pandemic: a qualitative study of a hospital-wide clinical event debriefing program and a novel qualitative model to analyze debriefing content. November 16, 2022
Outcomes of concurrent operations: results from the American College of Surgeons' National Surgical Quality Improvement Program. October 11, 2017
Interview In Conversation with... Kathleen Sanford and Sue Schuelke about Virtual Nursing August 30, 2023
Perspectives on Safety Virtual Nursing: Improving Patient Care and Meeting Workforce Challenges August 30, 2023
Improving standardization of paging communication using quality improvement methodology. April 10, 2019
Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors. October 24, 2018
Effect of a pediatric early warning system on all-cause mortality in hospitalized pediatric patients. March 7, 2018
Improving communication with primary care physicians at the time of hospital discharge. February 8, 2017
Reliability of verbal handoff assessment and handoff quality before and after implementation of a resident handoff bundle. June 22, 2016
Why do we still page each other? Examining the frequency, types and senders of pages in academic medical services. February 3, 2016
A step toward high reliability: implementation of a daily safety brief in a children's hospital. September 24, 2014
The influence of organizational factors on patient safety: examining successful handoffs in health care. August 27, 2014
Physician attitudes toward family-activated medical emergency teams for hospitalized children. April 2, 2014
Implementation of a pediatric rapid response team: experience of the Hospital for Sick Children in Toronto. March 12, 2014
Assigning a team-based pager for on-call physicians reduces paging errors in a large academic hospital. February 12, 2014
Sign-out snapshot: cross-sectional evaluation of written sign-outs among specialties. January 15, 2014
Improvement of medication event interventions through use of an electronic database. December 18, 2013
Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. December 11, 2013
Impact of an automated email notification system for results of tests pending at discharge: a cluster-randomized controlled trial. November 27, 2013
An intervention model that promotes accountability: peer messengers and patient/family complaints. October 9, 2013
Principles supporting dynamic clinical care teams: an American College of Physicians position paper. September 25, 2013
What do patients think about year-end resident continuity clinic handoffs?: a qualitative study. May 22, 2013
Effect of a systems intervention on the quality and safety of patient handoffs in an internal medicine residency program. May 15, 2013
Hospital-initiated transitional care interventions as a patient safety strategy: a systematic review. March 20, 2013