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psnet.ahrq.gov/issue/non-technical-skills-training-enhance-patient-safety
August 04, 2021 - 10, 2024
Reduced postdischarge incidents after implementation of a hospital-to-home transition
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psnet.ahrq.gov/node/49840/psn-pdf
September 01, 2018 - past 20 years has consistently shown that medication adverse events often occur
surrounding times of transition … While this case supports the need for rigorous medication reconciliation at each care transition, it … Medication adverse events are common during times of transition in patient care (e.g., admission,
discharge
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psnet.ahrq.gov/issue/posthospital-medication-discrepancies-prevalence-and-contributing-factors
July 10, 2008 - February 10, 2021
Patient Safety Innovations
Transition
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psnet.ahrq.gov/issue/how-make-emergency-department-visit-safe-one
November 02, 2005 - 1, 2016
WebM&M Cases
Recurrent Hypoglycemia: A Care Transition
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psnet.ahrq.gov/issue/nursing-care-quality-nqf
September 06, 2011 - September 22, 2010
Work-arounds and artifacts during transition to a computer physician
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psnet.ahrq.gov/issue/human-factors-and-ergonomics-patient-safety
June 21, 2006 - February 23, 2018
Care transition of trauma patients: processes with articulation work
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psnet.ahrq.gov/issue/reused-devices-surgerys-deadly-suspects
January 04, 2006 - September 11, 2019
Cedars-Sinai doctors cling to pen and paper: transition to electronic
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psnet.ahrq.gov/issue/hospitals-save-money-safety-questioned
January 18, 2006 - May 18, 2005
Cedars-Sinai doctors cling to pen and paper: transition to electronic medical
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psnet.ahrq.gov/issue/special-issue-health-information-technology
August 22, 2007 - May 11, 2019
Handoffs and teamwork: a framework for care transition communication.
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psnet.ahrq.gov/issue/polypharmacy
May 07, 2008 - 17, 2019
Medication reconciliation: reducing risk for medication misadventure during transition
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psnet.ahrq.gov/issue/improving-medication-safety-during-hospital-based-transitions-care
May 08, 2017 - 11, 2014
Medication reconciliation: reducing risk for medication misadventure during transition
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psnet.ahrq.gov/node/33841/psn-pdf
September 01, 2017 - health record (EHR) system at Dartmouth and subsequently was the senior
physician leader during their transition … So, the transition to typed
notes, lab results, radiology reports, autopsy reports, and gross pathology … safety-assurance-factors-ehr-resilience-safer-guides
https://psnet.ahrq.gov/issue/adverse-inpatient-outcomes-during-transition-new-electronic-health-record-system … is unlikely to occur again—the federal government putting resources to enable people to
make this transition
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psnet.ahrq.gov/issue/care-transitions-outpatient-surgery-preoperative-process-facilitators-and-obstacles
December 31, 2014 - June 22, 2022
Care transition of trauma patients: processes with articulation work before
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psnet.ahrq.gov/web-mm/steroids-and-safety-preventing-medication-adverse-events-during-transitions-care
September 09, 2013 - past 20 years has consistently shown that medication adverse events often occur surrounding times of transition … While this case supports the need for rigorous medication reconciliation at each care transition, it … Medication adverse events are common during times of transition in patient care (e.g., admission, discharge … August 21, 2013
The hospital discharge: a review of a high risk care transition with
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.185_slideshow.ppt
October 01, 2008 - Spotlight Case July 2008
Spotlight Case
Recurrent Hypoglycemia:
A Care Transition Failure? … encounter, would provide additional safety
*
*
How a True EHR Could Have Helped
Facilitate transition
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psnet.ahrq.gov/issue/most-dangerous-time-hospital-it-may-be-when-you-leave
March 08, 2017 - August 30, 2017
Association between end-of-rotation resident transition in care and mortality
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psnet.ahrq.gov/node/49648/psn-pdf
March 01, 2012 - hospitalizations, and
outpatient visits.(5) Hospital-based transitional care interventions aim to smooth the transition … planning, a transitions coach (a provider, often a nurse, who is
responsible for coordinating the transition
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psnet.ahrq.gov/issue/diagnostic-error-medicine
October 22, 2013 - October 31, 2011
WebM&M Cases
A Seasonal Care Transition
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psnet.ahrq.gov/issue/national-time-out-day
December 08, 2015 - New graduate registered nurses: Risk mitigation strategies to ensure safety and successful transition
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psnet.ahrq.gov/issue/administering-saline-flush-site-unseen-can-lead-wrong-route-error
June 10, 2018 - June 10, 2018
Managing risk during transition to new ISO tubing connector standards.