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 (44)
Australia and New Zealand (18)
North America (657)
Journal Article (613)
Newspaper/Magazine Article (73)
Special or Theme Issue (10)
Web Resource (15)
Epidemiology of Errors and Adverse Events (229)
Active Errors (127)
Latent Errors (93)
Near Miss (5)
Approach to Improving Safety
Quality Improvement Strategies (132)
Legal and Policy Approaches (45)
Error Reporting and Analysis (118)
Communication Improvement (493)
Human Factors Engineering (52)
Specialization of Care (57)
Logistical Approaches (100)
Culture of Safety (33)
Technologic Approaches (136)
Education and Training (152)
Allied Health Services (3)
Health Care Providers (546)
Health Care Executives and Administrators (566)
Non-Health Care Professionals (226)
Setting of Care
Psychiatric Facilities (2)
Residential Facilities (16)
Ambulatory Care (111)
Outpatient Surgery (5)
Patient Transport (16)
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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.
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.
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.
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.
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.
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.
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.
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.
Implementation of a specialized pharmacy team to monitor high-risk medications during discharge.
Martin ES III, Overstreet RL, Jackson-Khalil LR, McCollough HL, Meyer TA, Xu Q. Am J Health Syst Pharm. 2013;70:18-21.
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.
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.
Hospital discharge documentation and risk of rehospitalisation.
Hansen LO, Strater A, Smith L, et al. BMJ Qual Saf. 2011;20:773-778.
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.
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.
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.
Evaluation of adverse drug events and medication discrepancies in transitions of care between hospital discharge and primary care follow-up.
Armor BL, Wight AJ, Carter SM. J Pharm Pract. 2014 Oct 13; [Epub ahead of print].
Design and implementation of an application and associated services to support interdisciplinary medication reconciliation efforts at an integrated healthcare delivery network.
Poon EG, Blumenfeld B, Hamann C, et al. J Am Med Inform Assoc. 2006;13:581-592.
Consequences of inadequate sign-out for patient care.
Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. Arch Intern Med. 2008;168:1755-1760.
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