AHRQ Patient Safety Network

The Collection > Discontinuities, Gaps, and Hand-Off Problems

PATIENT SAFETY PRIMERS
Adverse Events after Hospital Discharge
Handoffs and Signouts

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Discontinuities, Gaps, and Hand-Off Problems

•Missed or Critical Lab Results (42)

Origin/Sponsor

•Africa (1)

•Asia (4)

•Australia and New Zealand (30)

Resource Types

•Journal Article (584)

•Legislation/Regulation (11)

•Meeting/Conference (2)

•Newspaper/Magazine Article (75)

•Press Release/Announcement (1)

•Special or Theme Issue (13)

•Tools/Toolkit (11)

•Web Resource (18)

•Grant (4)

Error Types

•Epidemiology of Errors and Adverse Events (168)

•Active Errors (127)

•Latent Errors (79)

•Near Miss (7)

Approach to Improving Safety

•Quality Improvement Strategies (155)

•Legal and Policy Approaches (50)

•Error Reporting and Analysis (119)

•Communication Improvement (492)

•Human Factors Engineering (68)

•Teamwork (60)

•Specialization of Care (66)

•Logistical Approaches (120)

•Culture of Safety (52)

•Technologic Approaches (129)

•Education and Training (165)

Clinical Areas

•Allied Health Services (3)

•Medicine (575)

•Nursing (67)

•Pharmacy (65)

Target Audience

•Health Care Providers (550)

•Health Care Executives and Administrators (567)

•Non-Health Care Professionals (215)

•Patients (53)

Setting of Care

•Hospitals (539)

•Psychiatric Facilities (3)

•Residential Facilities (18)

•Ambulatory Care (107)

•Outpatient Surgery (6)

•Patient Transport (17)

1 - 20 of 753

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NEWSPAPER/MAGAZINE ARTICLE

Safety in ASCs: putting patients first.

Dix K. Today's Surgicenter. December 1, 2006.

COMMENTARY

Right? Left? Neither!

Howell EA, Chassin MR. AHRQ WebM&M [serial online]. May 2006.

REVIEW

Coordinating care across diseases, settings, and clinicians: a key role for the generalist in practice.

Stille CJ, Jerant A, Bell D, Meltzer D, Elmore JG. Ann Intern Med. 2005;142:700-708.

BOOK/REPORT

Improving America's Hospitals: The Joint Commission's Report on Quality and Safety 2008.

Oakbrook Terrace, IL: The Joint Commission; November 2008.

STUDY

Time of day effects on the incidence of anesthetic adverse events.

Wright MC, Phillips-Bute B, Mark JB, et al. Qual Saf Health Care. 2006;15:258-263.

BOOK/REPORT

Inspiring Ideas and Celebrating Successes: A Guidebook to Leading Patient Safety Practices in Ontario Hospitals.

OHA Patient Safety Support Service. Toronto, Ontario, Canada: Ontario Hospital Association; 2006.

COMMENTARY

The challenge of medication reconciliation.

Patient Safety & Quality Healthcare. May 10, 2006.

STUDY

Communication practices on 4 Harvard surgical services: a surgical safety collaborative.

ElBardissi AW, Regenbogen SE, Greenberg CC, et al. Ann Surg. 2009;250:861-865.

STUDY

The impact of the 80-hour resident workweek on surgical residents and attending surgeons.

Hutter MM, Kellogg KC, Ferguson CM, Abbott WM, Warshaw AL. Ann Surg. 2006;243:864-871; discussion 871-875.

ORGANIZATIONAL POLICY/GUIDELINES

AORN Guidance Statement: Safe Medication Practices in Perioperative Settings Across the Life Span.

AORN J. 2006;84:276-278, 280-283.

STUDY

Challenges in posthospital care: nurses as coaches for medication management.

Costa LL, Poe SS, Lee MC. J Nurs Care Qual. 2011;26:243-251.

STUDY

Patterns of communication breakdowns resulting in injury to surgical patients.

Greenberg CC, Regenbogen SE, Studdert DM, et al. J Am Coll Surg. 2007;204:533-540.

BOOK/REPORT classic

Safe Practices for Better Healthcare—2010 Update.

National Quality Forum. Washington, DC: National Quality Forum; 2010.

BOOK/REPORT

Medmarx Data Report: A Chartbook of Medication Error Findings from the Perioperative Settings from 1998-2005.

Rockville, MD: United States Pharmacopeia; 2007.

NEWSPAPER/MAGAZINE ARTICLE

Get me out alive.

Feldman R. The Washington Post. May 2, 2006:HE01.

STUDY

A randomized, controlled trial evaluating the impact of a computerized rounding and sign-out system on continuity of care and resident work hours.

Van Eaton EG, Horvath KD, Lober WB, Rossini AJ, Pellegrini CA. J Am Coll Surg. 2005;200:538-545.

BOOK/REPORT

Improving America's Hospitals: A Report on Quality and Safety.

Oakbrook Terrace, IL: The Joint Commission; March 2007.

STUDY

Risk of medication errors at hospital discharge and barriers to problem resolution.

Enguidanos SM, Brumley RD. Home Health Care Serv Q. 2005;24:123-135.

STUDY

Predictors of likelihood of speaking up about safety concerns in labour and delivery.

Lyndon A, Sexton JB, Simpson KR, Rosenstein A, Lee KA, Wachter RM. BMJ Qual Saf. 2012;21;791-799.

SPECIAL OR THEME ISSUE

Safety in EMS.

Brice JH, Patterson PD, eds. Prehosp Emerg Care. 2012;16:1-108.

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