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 (48)
Australia and New Zealand (34)
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Epidemiology of Errors and Adverse Events (228)
Active Errors (161)
Latent Errors (111)
Near Miss (7)
Approach to Improving Safety
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Non-Health Care Professionals (257)
Setting of Care
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Howell EA, Chassin MR. AHRQ WebM&M [serial online]. May 2006.
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.
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.
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.
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.
AORN Guidance Statement: Safe Medication Practices in Perioperative Settings Across the Life Span.
AORN J. 2006;84:276-278, 280-283.
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 challenge of medication reconciliation.
Patient Safety & Quality Healthcare. May 10, 2006.
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.
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.
Improving America's Hospitals: The Joint Commission's Report on Quality and Safety 2008.
Oakbrook Terrace, IL: The Joint Commission; November 2008.
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.
Safe Practices for Better Healthcare—2010 Update.
National Quality Forum. Washington, DC: National Quality Forum; 2010.
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.
Nursing home error and level of staff credentials.
Scott-Cawiezell J, Pepper GA, Madsen RW, Petroski G, Vogelsmeier A, Zellmer D. Clin Nurs Res. 2007;16:72-78.
Improving medication reconciliation in the outpatient setting.
Varkey P, Cunningham J, Bisping S. Jt Comm J Qual Patient Saf. 2007;33:286-292.
Handoffs causing patient harm: a survey of medical and surgical house staff.
Kitch BT, Cooper JB, Zapol WM, et al. Jt Comm J Qual Patient Saf. 2008;34:563-570.
Practitioners agree on medication reconciliation value, but frustration and difficulties abound.
ISMP Medication Safety Alert! Acute Care Edition. July 13, 2006;11:1-2.
Get me out alive.
Feldman R. The Washington Post. May 2, 2006:HE01.
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