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psnet.ahrq.gov/node/44951/psn-pdf
March 02, 2016 - This study examined
handoffs from the emergency department to the inpatient unit, a transition known … handoffs-and-signouts
https://psnet.ahrq.gov/issue/dropping-baton-qualitative-analysis-failures-during-transition-emergency-department-inpatient
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psnet.ahrq.gov/node/41192/psn-pdf
November 26, 2014 - reconciliation-errors
Medication reconciliation continues to pose significant threats to patients when they transition … This study found that reconciliation errors occurred frequently at both these transition
times; 42%
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psnet.ahrq.gov/node/33661/psn-pdf
December 01, 2007 - I would argue that a good
hospital discharge transition is just as important as a thorough admission … coach" and empowering
them to facilitate communication and other aspects of the care transition. … SHM is working with the American College of Physicians and other
organizations to develop care transition … As hospitalists, health systems, and regulatory
agencies become more invested in the care transition … Lost in transition: challenges and opportunities for improving the quality of
transitional care.
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psnet.ahrq.gov/issue/work-system-barriers-and-facilitators-team-health-information-technology
March 11, 2020 - technician, pediatric intensive care unit attending) on the usability of a potential team health IT care transition … September 11, 2019
Care transition of trauma patients: processes with articulation work
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psnet.ahrq.gov/issue/medical-malpractice-litigation-and-daylight-saving-time
March 24, 2019 - 288,432 malpractice claims between January 1990 and September 2018, researchers found that the spring transition … September 23, 2020
Increased patient safety-related incidents following the transition
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psnet.ahrq.gov/issue/effects-i-pass-nursing-handoff-bundle-communication-quality-and-workflow
November 12, 2014 - 31, 2014
Reduced postdischarge incidents after implementation of a hospital-to-home transition … 10, 2019
View More
Related Resources
Ensuring effective care transition … August 21, 2019
Making the transition to nursing bedside shift reports.
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psnet.ahrq.gov/node/40433/psn-pdf
November 26, 2014 - As CPOE systems evolve, health systems are
beginning to transition from older versions (with only limited … This analysis of a primary care practice that underwent such a transition found
fewer overall prescribing
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psnet.ahrq.gov/issue/information-management-goals-and-process-failures-during-home-visits-middle-aged-and-older
November 15, 2023 - Patients are at risk for adverse events after they transition from hospital to home. … The authors recommend redesigning the care transition process from hospital to home health care providers
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psnet.ahrq.gov/node/49632/psn-pdf
July 01, 2011 - A Seasonal Care Transition Failure
July 1, 2011
Young JQ. A Seasonal Care Transition Failure. … https://psnet.ahrq.gov/web-mm/seasonal-care-transition-failure
The Case
A 70-year-old healthy man presented … symptoms.(12-14) This
potentially heightened acuity makes monitoring even more critical during the transition … predicted those patients more likely to require hospitalization or have significant
symptoms during the transition … These may include specialized transition curricula, training in communication skills for
giving and
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psnet.ahrq.gov/issue/effect-multispecialty-faculty-handoff-initiative-safety-culture-and-handoff-quality
March 10, 2019 - Additionally, the “handoff and transition score” on the Agency for Healthcare Quality (AHRQ) Hospital … October 6, 2016
Physician transition of care: benefits of I-PASS and an electronic handoff
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psnet.ahrq.gov/node/38612/psn-pdf
May 06, 2009 - 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
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psnet.ahrq.gov/issue/measuring-psychological-safety-and-local-learning-enable-high-reliability-organisational
May 04, 2022 - measure (local learning) to measure staff psychological safety and evaluate the effectiveness of their transition … Medication-related interventions to improve medication safety and patient outcomes on transition
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psnet.ahrq.gov/training-catalog/improving-care-transitions-older-adults
Event Description: This program focuses on the role of the clinician in managing the care transition
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psnet.ahrq.gov/issue/effective-discharge-communication-emergency-department
January 24, 2024 - April 8, 2019
Facilitating a safe transition from the pediatric emergency department … 2010
WebM&M Cases
Recurrent Hypoglycemia: A Care Transition
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.194_slideshow.ppt
March 01, 2009 - ED-to-Inpatient Handoff
ED-to-inpatient handoff is another care transition that can lead to medical … Dropping the baton: a qualitative analysis of failures during the transition from emergency department … Dropping the baton: a qualitative analysis of failures during the transition from emergency department … Potential Solutions to Improve Transition
Improved electronic access to key information
Vital signs … Dropping the baton: a qualitative analysis of failures during the transition from emergency department
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psnet.ahrq.gov/node/47896
August 23, 2006 - A PSNet perspective discussed interventions to improve safety during the transition from hospital to … April 14, 2010
Patient Safety Innovations
Transition Coaches
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psnet.ahrq.gov/issue/using-stakeholder-intervention-refinement-teams-develop-approaches-real-time-integration
January 21, 2019 - 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
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psnet.ahrq.gov/issue/prescribing-discrepancies-likely-cause-adverse-drug-events-after-patient-transfer
December 08, 2010 - reconciliation was named as a 2005 National Patient Safety Goal in part to address these concerns at various transition … 16, 2019
Medication reconciliation: reducing risk for medication misadventure during transition
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psnet.ahrq.gov/issue/care-transitions-intervention-results-randomized-controlled-trial
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 continuity
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psnet.ahrq.gov/issue/resident-resident-handoffs-emergency-department-observational-study
September 28, 2022 - September 28, 2022
Assessing patient work system factors for medication management during transition … March 28, 2011
WebM&M Cases
Lost in Transition
February