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 (38)

Origin/Sponsor

•Africa (1)

•Asia (3)

•Australia and New Zealand (15)

Resource Types

•Journal Article (528)

•Legislation/Regulation (10)

•Meeting/Conference (1)

•Newspaper/Magazine Article (71)

•Special or Theme Issue (9)

•Tools/Toolkit (10)

•Web Resource (15)

•Grant (1)

Error Types

•Epidemiology of Errors and Adverse Events (190)

•Active Errors (95)

•Latent Errors (67)

•Near Miss (5)

Approach to Improving Safety

•Quality Improvement Strategies (122)

•Legal and Policy Approaches (39)

•Error Reporting and Analysis (106)

•Communication Improvement (432)

•Human Factors Engineering (47)

•Teamwork (44)

•Specialization of Care (55)

•Logistical Approaches (101)

•Culture of Safety (31)

•Technologic Approaches (117)

•Education and Training (144)

Clinical Areas

•Allied Health Services (3)

•Medicine (528)

•Nursing (54)

•Pharmacy (66)

Target Audience

•Health Care Providers (476)

•Health Care Executives and Administrators (484)

•Non-Health Care Professionals (186)

•Patients (50)

Setting of Care

•Hospitals (492)

•Psychiatric Facilities (2)

•Residential Facilities (14)

•Ambulatory Care (97)

•Outpatient Surgery (5)

•Patient Transport (12)

1 - 20 of 668

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STUDY

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.

STUDY

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.

STUDY

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.

STUDY

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.

STUDY

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.

STUDY

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.

STUDY

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.

STUDY

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.

COMMENTARY

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.

STUDY

Medication reconciliation during internal hospital transfer and impact of computerized prescriber order entry.

Lee JY, Leblanc K, Fernandes OA, et al. Ann Pharmacother. 2010;44:1887-1895.

STUDY

Safety of using a computerized rounding and sign-out system to reduce resident duty hours.

Van Eaton EG, McDonough K, Lober WB, Johnson EA, Pellegrini CA, Horvath KD. Acad Med. 2010;85:1189-1195.

COMMENTARY

Ten years after the IOM report: engaging residents in quality and patient safety by creating a house staff quality council.

Fleischut PM, Evans AS, Nugent WC, et al. Am J Med Qual. 2011;26:89-94.

STUDY

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.

COMMENTARY

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.

STUDY

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.

STUDY

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.

NEWSPAPER/MAGAZINE ARTICLE

Survey results: community liaison programs to decrease hospital readmissions.

ISMP Medication Safey Alert! Acute Care Edition. March 7, 2013;18:1-3.

STUDY

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.

STUDY

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.

STUDY

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.

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