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121. Using Human Factors Engineering and the SEIPS Model to Advance Patient Safety in Care Transitions | PSNet
     psnet.ahrq.gov/perspective/using-human-factors-engineering-and-seips-model-advance-patient-safety-care-transitions
     November 16, 2022 - Sarah Mossburg: This is a good point to transition into talking about the framework that you developed … We redesigned that care transition with multiple stakeholders. … Nicole Werner: Well, currently in our healthcare system, I would say, the only constant in a transition … And I think there’s been a historical tendency to think of a transition as a short time period like a … A care transition, from the ED or from any other healthcare setting, back to home or to another setting

122. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/855419/psn-pdf
     November 15, 2023 - older adults and their family caregivers, HH frontline providers, HH leadership, and HH hospital-based transition … coordinators, were engaged to identify best practices to implement the Hospital-to-Home Health Transition

123. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49691/psn-pdf
     September 01, 2013 - However, despite a few ambulatory visits for this patient since transition to the new EHR, the allergy … There is little published data on the prevalence of this type of transition. … Limited data is available about safety threats and other unintended consequences following the transition … We conducted an epidemiological study of prescribing errors after the transition from a homegrown EHR … Although there are no specific requirements for how to transition between EHRs, there are best practices

124. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/73120/psn-pdf
     April 07, 2021 - unintentional and the majority (62.1%) of those were found when comparing the prescriptions during the transition … psnet.ahrq.gov/issue/medication-errors-year-review https://psnet.ahrq.gov/issue/medication-errors-care-transition-trauma-patients

125. Broken, fragmented health-care system failed daughter who died by suicide. | PSNet
     psnet.ahrq.gov/issue/broken-fragmented-health-care-system-failed-daughter-who-died-suicide
     June 29, 2022 - suicide of a concussed woman whose care failed due to gaps in team communication, discharge and transition … April 15, 2020 Increased patient safety-related incidents following the transition into

126. In Conversation With... Pascale Carayon, PhD and Nicole Werner, PhD | PSNet
     psnet.ahrq.gov/perspective/conversation-pascale-carayon-phd-and-nicole-werner-phd
     November 16, 2022 - Sarah Mossburg: This is a good point to transition into talking about the framework that you developed … We redesigned that care transition with multiple stakeholders. … Nicole Werner: Well, currently in our healthcare system, I would say, the only constant in a transition … And I think there’s been a historical tendency to think of a transition as a short time period like a … A care transition, from the ED or from any other healthcare setting, back to home or to another setting

127. Does standardisation improve post-operative anaesthesia handoffs? Meta-analyses on provider, patient, organisational, and handoff outcomes. | PSNet
     psnet.ahrq.gov/issue/does-standardisation-improve-post-operative-anaesthesia-handoffs-meta-analyses-provider
     June 29, 2022 - Related Resources From the Same Author(s) Handoffs and teamwork: a framework for care transition … Medication-related interventions to improve medication safety and patient outcomes on transition … March 9, 2022 Care transition of trauma patients: processes with articulation work before

128. Assessing controlled substance prescribing errors in a pediatric teaching hospital: an analysis of the safety of analgesic prescription practice in the transition from the hospital to home. | PSNet
     psnet.ahrq.gov/issue/assessing-controlled-substance-prescribing-errors-pediatric-teaching-hospital-analysis-safety
     August 02, 2010 - a pediatric teaching hospital: an analysis of the safety of analgesic prescription practice in the transition … a pediatric teaching hospital: an analysis of the safety of analgesic prescription practice in the transition … a pediatric teaching hospital: an analysis of the safety of analgesic prescription practice in the transition

129. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/47045/psn-pdf
     January 21, 2019 - information-management-goals-and-process-failures-during-home-visits- middle-aged-and-older Patients are at risk for adverse events after they transition … The authors recommend redesigning the care transition process from hospital to home health care providers

130. Adapting The Joint Commission's seven foundations of safe and effective transitions of care to home. | PSNet
     psnet.ahrq.gov/issue/adapting-joint-commissions-seven-foundations-safe-and-effective-transitions-care-home
     July 10, 2024 - this commentary discusses how health care organizations are applying these principles to enhance care transition … 2024 Reduced postdischarge incidents after implementation of a hospital-to-home transition

131. DRESSed for Failure | PSNet
     psnet.ahrq.gov/web-mm/dressed-failure
     September 01, 2011 - However, despite a few ambulatory visits for this patient since transition to the new EHR, the allergy … There is little published data on the prevalence of this type of transition. … We conducted an epidemiological study of prescribing errors after the transition from a homegrown EHR … to a new commercial EHR that demonstrated an increase in many types of errors soon after the transition … Although there are no specific requirements for how to transition between EHRs, there are best practices

132. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45017/psn-pdf
     April 13, 2016 - See One, Sim One, Do One"—a national pre-internship boot-camp to ensure a safer "student to doctor" transition … See One, Sim One, Do One"- A National Pre-Internship Boot-Camp to Ensure a Safer "Student to Doctor" Transition

133. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41440/psn-pdf
     August 17, 2016 - The updated toolkit represents adjustments made to the AHRQ Quality Indicators to support the transition … toolkit-using-ahrq-quality-indicators-how-improve-hospital-quality-and-safety https://psnet.ahrq.gov/issue/challenges-and-remediation-patient-safety-indicators-transition-icd

134. Engineering care transitions: clinician perceptions of barriers to safe medication management during transitions of patient care. | PSNet
     psnet.ahrq.gov/issue/engineering-care-transitions-clinician-perceptions-barriers-safe-medication-management-during
     July 20, 2022 - Aligning clinician and patient care transition goals using these three strategies may better prepare … July 21, 2021 Care transition of trauma patients: processes with articulation work before

135. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49749/psn-pdf
     December 01, 2015 - Diabetes care guidelines discuss the transition from intravenous (IV) to subcutaneous insulin in patients … Glucommander also has a specific module to assist with transition from IV to subcutaneous insulin. … In this case, the physician did not use the Glucommander for the insulin transition, and the ICU nurse … //psnet.ahrq.gov//#table https://psnet.ahrq.gov//#references Guidelines exist to support the safe transition … off of insulin drip Protocols to guide transition from IV to subcutaneous insulin and insulin management

136. Hyperglycemia and Switching to Subcutaneous Insulin | PSNet
     psnet.ahrq.gov/web-mm/hyperglycemia-and-switching-subcutaneous-insulin
     May 19, 2021 - Diabetes care guidelines discuss the transition from intravenous (IV) to subcutaneous insulin in patients … should be in the target range of 140–180 and stable for at least 4 hours on the insulin infusion before transition … Glucommander also has a specific module to assist with transition from IV to subcutaneous insulin. … In this case, the physician did not use the Glucommander for the insulin transition, and the ICU nurse … off of insulin drip Protocols to guide transition from IV to subcutaneous insulin and insulin management

137. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/44202/psn-pdf
     June 10, 2015 - medication errors due to polypharmacy and coexisting conditions, resulting in the need for enhanced transition … https://psnet.ahrq.gov/primer/medication-reconciliation https://psnet.ahrq.gov/issue/facilitating-safe-transition-pediatric-emergency-department-home-post-discharge-phone-call

138. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36333/psn-pdf
     July 10, 2008 - studies have documented the safety problems that befall patients with complex illnesses at the time of transition … Intervention patients received a personal health record and a "transition coach," who assisted with

139. Discharge Planning and Transitions of Care | PSNet
     psnet.ahrq.gov/primer/discharge-planning-and-transitions-care
     September 07, 2019 - The transition from hospital to home can be challenging as patients and families become responsible for … California, Davis Health sabajorek@ucdavis.edu Vanessa McElroy, RN, BSN, PHN, ACM-RN IQCI Director, Care Transition … The hospital discharge: a review of a high risk care transition with highlights of a reengineered discharge … July 14, 2021 View More Related WebM&M Transition to Nowhere April 1,

140. Optimizing transitions of care to reduce rehospitalizations. | PSNet
     psnet.ahrq.gov/issue/optimizing-transitions-care-reduce-rehospitalizations
     November 04, 2015 - to reduce readmissions , such as enhancing team communication, educating staff, and standardizing transition … December 19, 2018 Challenges and remediation for Patient Safety Indicators in the transition