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psnet.ahrq.gov/issue/using-stakeholder-intervention-refinement-teams-develop-approaches-real-time-integration
January 21, 2019 - integration of patient-reported safety information during older adults’ hospital-to-home-health care transitions … integration of patient-reported safety information during older adults’ hospital-to-home-health care transitions … integration of patient-reported safety information during older adults’ hospital-to-home-health care transitions … December 21, 2017
Learning from lawsuits: using malpractice claims data to develop care transitions
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psnet.ahrq.gov/issue/new-professionalism-surgical-residents-duty-hours-restrictions-and-shift-transitions
October 19, 2022 - Surgical residents, duty hours restrictions, and shift transitions. … Surgical residents, duty hours restrictions, and shift transitions. … Surgical residents, duty hours restrictions, and shift transitions.
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psnet.ahrq.gov/node/865585/psn-pdf
April 17, 2024 - issue/estimating-impact-patient-safety-enabling-digital-transfer-patients-prescription-
information
Transitions … This study estimates
the prevalence and burden of medication errors at transitions of care (hospital … estimating-impact-patient-safety-enabling-digital-transfer-patients-prescription-information
https://psnet.ahrq.gov/primer/inpatient-transitions-care-challenges-and-safety-practices
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psnet.ahrq.gov/issue/intervention-improve-transitions-nicu-ambulatory-care-quasi-experimental-study
December 30, 2014 - Study
An intervention to improve transitions from NICU to ambulatory care: quasi-experimental … An intervention to improve transitions from NICU to ambulatory care: quasi-experimental study. … An intervention to improve transitions from NICU to ambulatory care: quasi-experimental study.
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psnet.ahrq.gov/node/33569/psn-pdf
September 07, 2019 - Systematic problems in care transitions are at the root of most adverse events that arise after discharge … Preventing Adverse Events After Discharge
Ensuring safe care transitions requires a systematic approach … These studies, the Care Transitions trial and the Project RED
study, both successfully reduced readmissions … Evaluating the effectiveness of care transitions interventions is hindered by the fact that the standard … patients are readmitted likely vary
between hospitals and patient populations, indicating that care transitions
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psnet.ahrq.gov/node/74055/psn-pdf
January 01, 2022 - doctors' experiences of
patient safety in health information exchange during
interorganizational care transitions … doctors' experiences of
patient safety in health information exchange during interorganizational care transitions … physicians’ and nurses’ perspectives on patient safety related to use of HIE in
interorganizational care transitions
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psnet.ahrq.gov/web-mm/lost-transitions-care-managing-opioid-dependent-patient-frequent-hospitalizations
October 27, 2022 - SPOTLIGHT CASE
Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent … Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations. … Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations. … When patients with chronic conditions seek pain relief in multiple different care settings, transitions … Lost in Transitions of Care: Managing an Opioid-Dependent Patient with Frequent Hospitalizations.
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psnet.ahrq.gov/issue/handoff-tool-improves-transitions-operating-room-neonatal-intensive-care-unit
November 16, 2022 - Study
Handoff tool improves transitions from the operating room to the neonatal intensive … Handoff tool improves transitions from the operating room to the neonatal intensive care unit. … Handoff tool improves transitions from the operating room to the neonatal intensive care unit.
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psnet.ahrq.gov/node/44202/psn-pdf
June 10, 2015 - Medication reconciliation to facilitate transitions of care
after hospitalization. … Medication reconciliation to facilitate transitions of care after hospitalization. … https://psnet.ahrq.gov/issue/medication-reconciliation-facilitate-transitions-care-after-hospitalization … https://psnet.ahrq.gov/issue/medication-reconciliation-facilitate-transitions-care-after-hospitalization
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psnet.ahrq.gov/node/73517/psn-pdf
July 21, 2021 - Disparate perspectives: exploring healthcare
professionals' misaligned mental models of older adults'
transitions … Disparate perspectives: exploring healthcare professionals'
misaligned mental models of older adults’ transitions … that these healthcare professionals had misaligned mental
models regarding communication during care transitions
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psnet.ahrq.gov/issue/prescribing-discrepancies-likely-cause-adverse-drug-events-after-patient-transfer
December 08, 2010 - safety issue, with the resulting errors stemming from unintended events as well as from the broader transitions … This study analyzed more than 200 patients' medication records during transitions between acute hospital … March 9, 2022
Pharmacist-led program to improve transitions from acute care to skilled … March 23, 2011
Medication discrepancies upon hospital to skilled nursing facility transitions
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psnet.ahrq.gov/node/47403/psn-pdf
November 07, 2018 - Defining minimum necessary anticoagulation-related
communication at discharge: Consensus of the Care
Transitions … Defining Minimum Necessary Anticoagulation-Related Communication
at Discharge: Consensus of the Care Transitions … anticoagulants, are at increased risk for adverse drug
events and may be particularly vulnerable during care transitions
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.116_slideshow.ppt
February 01, 2006 - in continuously operating industries
Review cognitive error
Describe the complex dynamics of transitions … Transitions in care: studying safety in emergency department signovers. … Transitions in care: studying safety in emergency department signovers. … Phases of ED Transitions
Pre-turnover
Arrival
Meeting period
Post-turnover
Matthews AL, et al. … Improving Transitions
Reduce transitions when not necessary
Assure clear delineation of authority and
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psnet.ahrq.gov/issue/high-reliability-and-i-pass-communication-tool
June 02, 2021 - system used handoff standardization tools such as I-PASS to enhance the reliability of patient transitions … May 23, 2018
Crossing the communication chasm: challenges and opportunities in transitions … October 31, 2017
Care transitions know-how not just for clinicians.
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psnet.ahrq.gov/node/41527/psn-pdf
July 18, 2012 - Improving Transitions of Care: Hand-off Communications. … https://psnet.ahrq.gov/issue/improving-transitions-care-hand-communications
This tool describes factors … https://psnet.ahrq.gov/issue/improving-transitions-care-hand-communications
https://psnet.ahrq.gov/primer
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psnet.ahrq.gov/node/38558/psn-pdf
February 18, 2011 - Medication discrepancies upon hospital to skilled nursing
facility transitions. … Medication discrepancies upon hospital to skilled nursing facility
transitions. … https://psnet.ahrq.gov/issue/medication-discrepancies-upon-hospital-skilled-nursing-facility-transitions … https://psnet.ahrq.gov/issue/medication-discrepancies-upon-hospital-skilled-nursing-facility-transitions
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psnet.ahrq.gov/issue/hospitals-put-emphasis-collection-medication-data
September 14, 2011 - Related Resources
Patient Safety Primers
Inpatient Transitions … Diagnostic Safety and Quality
April 26, 2023
Pharmacist-led program to improve transitions … July 8, 2020
Applying the Medications at Transitions and Clinical Handoffs Toolkit in … June 10, 2018
Promoting effective transitions of care at hospital discharge: a review … October 18, 2016
Preventing medication errors in transitions of care: a patient case
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psnet.ahrq.gov/perspective/conversation-pascale-carayon-phd-and-nicole-werner-phd
November 16, 2022 - : any time a patient transitions from one broad environment of care setting to another. … We know that transitions are vulnerable times that need a lot of attention. … From an HFE perspective, care transitions are a process that spans two distinct work systems. … Another PSLL also examined patient transitions, specifically medication transitions , or changes in … Medication transitions: vulnerable periods of change in need of human factors and ergonomics.
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psnet.ahrq.gov/issue/handover-improving-continuity-patient-care-through-identification-and-implementation-novel
December 18, 2013 - This Web site offers information and resources for a project to improve care transitions. … February 13, 2013
Transitions of Care (TOC) Portal.
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psnet.ahrq.gov/node/33559/psn-pdf
September 07, 2019 - Patients often receive new medications or have changes made to their existing medications at times of
transitions … Medication
reconciliation refers to the process of avoiding such inadvertent inconsistencies across transitions … processes could prevent
medication discrepancies and potential ADEs at hospital admission, in-hospital transitions … focused on attempting to prevent medication errors at
hospital admission, discharge, or in-patient transitions … drug-related-problems-and-polypharmacy-nursing-home-residents-cross-sectional-study
https://psnet.ahrq.gov/issue/pharmacist-led-program-improve-transitions-acute-care-skilled-nursing-facility-care