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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/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/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/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/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/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/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.323_slideshow.ppt
May 01, 2014 - Lost in transition: challenges and opportunities for improving the quality of transitional care. … 8
This Case
A pharmacist completed an "official medication reconciliation" during a period of care transition
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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/node/866353/psn-pdf
July 24, 2024 - A clinical pharmacist-led transitions of care program for
veterans with two planned care transitions (hospital to
skilled care and skilled care to home) amid the COVID-19
pandemic.
July 24, 2024
Scannell GA, Bevan DJ, Cowan A, et al. A clinical pharmacist-led transitions of care program for veterans
with two plan…
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psnet.ahrq.gov/issue/stakeholder-perspectives-handovers-between-hospital-staff-and-general-practitioners
October 03, 2012 - April 20, 2014
Mitigating error vulnerability at the transition of care through the use
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psnet.ahrq.gov/web-mm/it-safe-be-direct
September 30, 2015 - Development of a brief "transition record" with listing of diagnoses and medications would facilitate … would eliminate redundant steps and multiple handoffs while implementing safeguards to facilitate the transition … unsupervised boarding time, and implementing safeguards such as a triage protocol will allow for a smoother transition
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psnet.ahrq.gov/web-mm/admission-drug-dose-too-low
September 01, 2011 - orders to all of the medications that the patient has been taking.( 2 ) This should be done at every transition … Safety Goal, focusing nationwide attention on the issue of inpatient medication errors as patients transition … called to the floor was not appropriately acted upon, perhaps secondary to nursing inexperience, a 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/quick-safety
May 30, 2012 - February 14, 2017
Adverse inpatient outcomes during the transition to a new electronic
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psnet.ahrq.gov/issue/quality-improvement-series
July 05, 2013 - June 2, 2010
Increased patient safety-related incidents following the transition into
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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.
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psnet.ahrq.gov/issue/hospital-takes-page-toyota
April 03, 2005 - Related Resources From the Same Author(s)
Cedars-Sinai doctors cling to pen and paper: 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/hospital-error-oversight-called-lax-state-takes-too-long-investigate-mistakes-patient
May 04, 2015 - July 13, 2022
Cedars-Sinai doctors cling to pen and paper: transition to electronic medical