U.S. Department of Health & Human Services
Discontinuities, Gaps, and Hand-Off Problems
PATIENT SAFETY PRIMERS
Adverse Events after Hospital Discharge
Handoffs and Signouts
2014 ANNUAL PERSPECTIVES
Handoffs and Transitions
Discontinuities, Gaps, and Hand-Off Problems
Missed or Critical Lab Results (49)
Australia and New Zealand (34)
North America (688)
Journal Article (685)
Newspaper/Magazine Article (75)
Press Release/Announcement (1)
Special or Theme Issue (15)
Web Resource (17)
Epidemiology of Errors and Adverse Events (213)
Active Errors (161)
Latent Errors (111)
Near Miss (7)
Approach to Improving Safety
Quality Improvement Strategies (168)
Legal and Policy Approaches (56)
Error Reporting and Analysis (136)
Communication Improvement (559)
Human Factors Engineering (75)
Specialization of Care (69)
Logistical Approaches (120)
Culture of Safety (54)
Technologic Approaches (152)
Education and Training (173)
Allied Health Services (3)
Health Care Providers (625)
Health Care Executives and Administrators (665)
Non-Health Care Professionals (254)
Setting of Care
Psychiatric Facilities (3)
Residential Facilities (20)
Ambulatory Care (125)
Outpatient Surgery (6)
Patient Transport (21)
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Safety in ASCs: putting patients first.
Dix K. Today's Surgicenter. December 1, 2006.
Right? Left? Neither!
Howell EA, Chassin MR. AHRQ WebM&M [serial online]. May 2006.
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.
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.
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.
AORN Guidance Statement: Safe Medication Practices in Perioperative Settings Across the Life Span.
AORN J. 2006;84:276-278, 280-283.
Engaging residents and fellows to improve institution-wide quality: the first six years of a novel financial incentive program.
Vidyarthi AR, Green AL, Rosenbluth G, Baron RB. Acad Med. 2014;89:460-468.
Challenges in posthospital care: nurses as coaches for medication management.
Costa LL, Poe SS, Lee MC. J Nurs Care Qual. 2011;26:243-251.
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.
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.
The challenge of medication reconciliation.
Patient Safety & Quality Healthcare. May 10, 2006.
Improving America's Hospitals: The Joint Commission's Report on Quality and Safety 2008.
Oakbrook Terrace, IL: The Joint Commission; November 2008.
An intervention to improve transitions from NICU to ambulatory care: quasi-experimental study.
Moyer VA, Papile LA, Eichenwald E, Giardino AP, Khan MM, Singh H. BMJ Qual Saf. 2014;23:e3.
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.
The content and context of change of shift report on medical and surgical units.
Staggers N, Jennings BM. J Nurs Adm. 2009;39:393-398.
Practitioners agree on medication reconciliation value, but frustration and difficulties abound.
ISMP Medication Safety Alert! Acute Care Edition. July 13, 2006;11:1-2.
SPECIAL OR THEME ISSUE
Patient Safety in Pediatric Emergency Medicine.
Frush KS, Hohenhaus SM, eds. Clin Ped Emerg Med. 2006;7:213-277.
The Patients' View: 2004 ISQSH National Survey.
Dublin, Ireland: Irish Society for Quality & Safety in Healthcare; 2005.
Ways to avert potential patient care disasters.
Spath P. Hosp Peer Rev. 2006;31:128-130.
Improving medication reconciliation in the outpatient setting.
Varkey P, Cunningham J, Bisping S. Jt Comm J Qual Patient Saf. 2007;33:286-292.
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