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psnet.ahrq.gov/node/843052/psn-pdf
January 25, 2023 - issue/improving-communication-hospital-skilled-nursing-facility-through-
standardized-hand-quality
Transitions
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psnet.ahrq.gov/node/60701/psn-pdf
July 22, 2020 - readmissions-and-adverse-events-after-discharge
https://psnet.ahrq.gov/issue/evaluation-adverse-drug-events-and-medication-discrepancies-transitions-care-between-hospital
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psnet.ahrq.gov/node/857454/psn-pdf
January 01, 2024 - The purpose of this scoping review was to identify measures evaluating the safety of HRM during
transitions
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psnet.ahrq.gov/web-mm/insulin-administration-pen-vs-vial-similar-not-interchangeable
December 20, 2023 - medication errors are common in hospital settings and can be especially problematic when a patient transitions … all parties involved . 9 This patient’s case highlights a patient safety issue that can arise during transitions … collaboration across providers plays a vital role in patient safety by decreasing risk for errors during transitions
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psnet.ahrq.gov/issue/targeted-medication-safety-best-practices-hospitals
January 26, 2023 - 2024-2025 edition includes new practices that are associated with tranexamic acid wrong-route errors, transitions
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psnet.ahrq.gov/issue/pharmacy-led-medication-reconciliation-best-practice
September 30, 2020 - Medication reconciliation should be completed at admission, discharge, and during transitions of care
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psnet.ahrq.gov/node/72815/psn-pdf
March 10, 2021 - perils-cross-coverage
https://psnet.ahrq.gov/issue/developing-standard-handoff-process-operating-room-icu-transitions-multidisciplinary
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psnet.ahrq.gov/issue/reduced-postdischarge-incidents-after-implementation-hospital-home-transition-intervention
September 06, 2023 - March 12, 2025
Annual Perspective
Communication During Transitions
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psnet.ahrq.gov/innovation/team-developed-care-plan-and-ongoing-care-management-social-workers-and-nurse
July 23, 2024 - GRACE was used as a care transitions and longitudinal care management model. … poorly integrated with primary care and mental health services and often fail to adequately manage care transitions … Extended Care at the VA, and the Centers for Medicare and Medicaid Services to participate in a care transitions … health system; thus, a faster return on investment can be found when GRACE is implemented as a care transitions … 23, 2024
Annual Perspective
Communication During Transitions
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psnet.ahrq.gov/issue/using-medication-containers-during-pharmacist-transitional-care-visits-and-impact-medication
March 08, 2023 - reconciliation is to prevent adverse events by identifying unintended medication discrepancies during transitions
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psnet.ahrq.gov/web-mm/recurrent-hypoglycemia-care-transition-failure
December 23, 2020 - SPOTLIGHT CASE
Recurrent Hypoglycemia: A Care Transition Failure?
Citation Text:
Eytan T. Recurrent Hypoglycemia: A Care Transition Failure?. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2008.
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Format:…
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psnet.ahrq.gov/web-mm/double-trouble
August 01, 2012 - their medications, and (iv) the need to improve communication and information transfer at times of transitions … causes, using an instrument such as the Medication Discrepancy Tool ( Figure ) produced by the Care Transitions … with specific emphasis on possible points of confusion, and perform medication reconciliation at all transitions … Medication Discrepancy Tool Produced by Care Transitions Program at University of Colorado at Denver
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psnet.ahrq.gov/web-mm/discharge-instructions-pacu-who-remembers
August 05, 2009 - patient–provider communication and specifically highlights the significance of these interactions during transitions … Transitions in care, such as those that occur at discharge from the emergency department (ED), day surgery … important aspect of patient care, which has significant implications for patient outcomes at times of transitions … discharge, and enhanced coordination of care with other providers may improve patient outcomes at times of transitions
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psnet.ahrq.gov/issue/identifying-and-mapping-measures-medication-safety-during-transfer-care-digital-era-scoping
July 24, 2024 - The purpose of this scoping review was to identify measures evaluating the safety of HRM during transitions
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psnet.ahrq.gov/issue/safe-intrahospital-transport-non-icu-patient-using-standardized-handoff-communication
March 18, 2010 - This article discusses strategies to ensure safe transitions for patients between hospital departments
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psnet.ahrq.gov/perspective/approach-improving-patient-safety-communication
August 31, 2020 - Jeffery Schnipper, a subject matter expert in care transitions and communication among healthcare providers … throughout a patient’s interaction with the health care system, including during diagnosis, treatment, and transitions … 27, 2024
Annual Perspective
Communication During Transitions
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psnet.ahrq.gov/web-mm/home-medications-contribute-unique-opportunity-error-discharge-hospital
May 16, 2022 - contributing to patient suffering, healthcare expenses, and distrust within the healthcare system. 1 Transitions … an especially vulnerable time for patients, and unfortunately the risk of medical error during these transitions … Going home on the right medications: prescription errors and transitions of care.
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psnet.ahrq.gov/issue/effect-patient-and-family-centered-i-pass-adverse-event-rates-hospitalized-children-complex
November 16, 2022 - I-PASS , a structured hand-off tool, can reduce preventable adverse events during transitions of care
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psnet.ahrq.gov/primer/ambulatory-care-safety
December 15, 2024 - Poorly handled care transitions (e.g., when a patient is discharged from the hospital or when care … April 10, 2024
Patient Safety Primers
Inpatient Transitions
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psnet.ahrq.gov/issue/lives-and-dollars-lost-calculator
June 21, 2023 - December 18, 2013
Transitions of Care (TOC) Portal.