U.S. Department of Health & Human Services
Discontinuities, Gaps, and Hand-Off Problems
PATIENT SAFETY PRIMERS
Adverse Events after Hospital Discharge
Handoffs and Signouts
Discontinuities, Gaps, and Hand-Off Problems
Missed or Critical Lab Results (42)
Australia and New Zealand (18)
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Journal Article (604)
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Epidemiology of Errors and Adverse Events (221)
Active Errors (124)
Latent Errors (92)
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Approach to Improving Safety
Quality Improvement Strategies (130)
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Setting of Care
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Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study.
Walker PC, Bernstein SJ, Tucker Jones JN, et al. Arch Intern Med. 2009;169:2003-2010.
Impact of a pharmacist on medication reconciliation on patient admission to a Veterans Affairs Medical Center.
Strunk LB, Matson AW, Steinke D. Hosp Pharm. 2008;43:643-649.
Quality improvement through implementation of discharge order reconciliation.
Lu Y, Clifford P, Bjorneby A, et al. Am J Health Syst Pharm. 2013;70:815-820.
Medication details documented on hospital discharge: cross-sectional observational study of factors associated with medication non-reconciliation.
Grimes TC, Duggan CA, Delaney TP, et al. Br J Clin Pharmacol. 2011;71:449-457.
Discrepancies between home medications listed at hospital admission and reported medical conditions.
Slain D, Kincaid SE, Dunsworth TS. Am J Geriatr Pharmacother. 2008;6:161-166.
Results of the Medications At Transitions and Clinical Handoffs (MATCH) study: an analysis of medication reconciliation errors and risk factors at hospital admission.
Gleason KM, McDaniel MR, Feinglass J, et al. J Gen Intern Med. 2010;25:441-447.
Clinical and safety impact of an inpatient pharmacist-directed anticoagulation service.
Schillig J, Kaatz S, Hudson M, Krol GD, Szandzik EG, Kalus JS. J Hosp Med. 2011;6:322-328.
Medication reconciliation for reducing drug-discrepancy adverse events.
Boockvar KS, Carlson Lacorte H, Giambanco V, Fridman B, Siu A. Am J Geriatr Pharmacother. 2006;4:236-243.
Assessment of adverse drug events among patients in a tertiary care medical center.
Johnston PE, France DJ, Byrne DW, et al. Am J Health Syst Pharm. 2006;63:2218-2227.
Effect of an electronic medication reconciliation application and process redesign on potential adverse drug events: a cluster-randomized trial.
Schnipper JL, Hamann C, Ndumele CD, et al. Arch Intern Med. 2009;169:771-780.
Survey results: community liaison programs to decrease hospital readmissions.
ISMP Medication Safey Alert! Acute Care Edition. March 7, 2013;18:1-3.
Saving lives by studying deaths: using standardized mortality reviews to improve inpatient safety.
Lau H, Litman KC. Jt Comm J Qual Patient Saf. 2011;37:400-408.
Improving the discharge process by embedding a discharge facilitator in a resident team.
Finn KM, Heffner R, Chang Y, et al. J Hosp Med. 2011;6:494-500.
Deficits in discharge documentation in patients transferred to rehabilitation facilities on anticoagulation: results of a systemwide evaluation.
Gandara E, Moniz TT, Ungar J, et al. Jt Comm J Qual Patient Saf. 2008;34:460-463.
Following the patient journey to improve medicines management and reduce errors.
Crocker C. Nurs Times. 2009 Nov 24;105:12-15.
Medication reconciliation in a community, nonteaching hospital.
Wortman SB. Am J Health Syst Pharm. 2008;65:2047-2054.
The effect of medication reconciliation in elderly patients at hospital discharge.
Midlöv P, Bahrani L, Seyfali M, Höglund P, Rickhag E, Eriksson T. Int J Clin Pharm. 2012;34:113-119.
Developing a programme for medication reconciliation at the time of admission into hospital.
Manzorro AG, Zoni AC, Rieiro CR, et al. Int J Clin Pharm. 2011;33:603-609.
Physician reporting of clinically significant events through a computerized patient sign-out system.
Nabors C, Peterson SJ, Aronow WS, et al. J Patient Saf. 2011;7:154-160.
Implementing online medication reconciliation at a large academic medical center.
Bails D, Clayton K, Roy K, Cantor MN. Jt Comm J Qual Patient Saf. 2008;34:499-508.
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