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 (39)
Australia and New Zealand (18)
North America (641)
Journal Article (597)
Newspaper/Magazine Article (72)
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Web Resource (15)
Epidemiology of Errors and Adverse Events (217)
Active Errors (123)
Latent Errors (90)
Near Miss (5)
Approach to Improving Safety
Quality Improvement Strategies (130)
Legal and Policy Approaches (45)
Error Reporting and Analysis (114)
Communication Improvement (484)
Human Factors Engineering (51)
Specialization of Care (56)
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Allied Health Services (3)
Health Care Providers (533)
Health Care Executives and Administrators (554)
Non-Health Care Professionals (217)
Setting of Care
Psychiatric Facilities (2)
Residential Facilities (16)
Ambulatory Care (108)
Outpatient Surgery (5)
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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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