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Diagnostic Safety and Quality

Diagnostic Safety Across Transitions of Care Throughout the Healthcare System: Current State and a Call to Action

References

  1. National Academies of Sciences, Engineering, and Medicine, Institute of Medicine, Board on Health Care Services, Committee on Diagnostic Error in Health Care. Improving Diagnosis in Health Care. Washington, DC: National Academies Press; 2016. https://www.ncbi.nlm.nih.gov/books/NBK338596/. Accessed May 3, 2023.
  2. Patterson ES, Roth EM, Woods DD, Chow R, Gomes JO. Handoff strategies in settings with high consequences for failure: lessons for health care operations. Int J Qual Health Care. 2004;16(2):125-132. https://pubmed.ncbi.nlm.nih.gov/15051706/. Accessed May 3, 2023.
  3. Bhise V, Rajan SS, Sittig DF, Morgan RO, Chaudhary P, Singh H. Defining and measuring diagnostic uncertainty in medicine: a systematic review. J Gen Intern Med. 2018;33(1):103-115. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5756158/. Accessed May 3, 2023.
  4. Hewson MG, Kindy PJ, Van Kirk J, Gennis VA, Day RP. Strategies for managing uncertainty and complexity. J Gen Intern Med. 1996;11(8):481-485. https://pubmed.ncbi.nlm.nih.gov/8872786/. Accessed May 3, 2023.
  5. The Joint Commission. Hot Topics in Health Care, Issue# 2. Transitions of Care: The Need for Collaboration Across Entire Care Continuum. Published online 2013.
  6. Raven MC, Lowe RA, Maselli J, Hsia RY. Comparison of presenting complaint vs discharge diagnosis for identifying “nonemergency” emergency department visits. JAMA. 2013;309(11):1145-1153. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3711676/. Accessed May 3, 2023.
  7. Chiu HS, Chan KF, Chung CH, Ma K, Au KW. A comparison of emergency department admission diagnoses and discharge diagnoses: retrospective study. Hong Kong J Emerg Med. 2003;10(2):70-75. https://doi.org/10.1177/102490790301000202. Accessed May 3, 2023.
  8. Balaguer Martínez JV, Gabriel Botella F, Braso Aznar JV, Núñez Sánchez C, Catalá Barceló T, Labios Gómez M. [The role of clinical autopsy in monitoring the quality of the clinical diagnosis in an emergency department]. An Med Interna. 1998;15(4):179-182. https://pubmed.ncbi.nlm.nih.gov/9608059/. Accessed May 3, 2023.
  9. Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, Hebert L, Newhouse JP, Weiler PC, Hiatt H. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324(6):377-384. https://www.nejm.org/doi/10.1056/NEJM199102073240605. Accessed May 3, 2023.
  10. Handler JA, Gillam M, Sanders AB, Klasco R. Defining, identifying, and measuring error in emergency medicine. Acad Emerg Med. 2000;7(11):1183-1188. https://pubmed.ncbi.nlm.nih.gov/11073465/. Accessed May 3, 2023.
  11. Thomas EJ, Studdert DM, Burstin HR, Orav EJ, Zeena T, Williams EJ, Howard KM, Weiler PC, Brennan TA. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care. 2000;38(3):261-271. https://pubmed.ncbi.nlm.nih.gov/10718351/. Accessed May 3, 2023.
  12. Horwitz LI, Meredith T, Schuur JD, Shah NR, Kulkarni RG, Jenq GY. Dropping the baton: a qualitative analysis of failures during the transition from emergency department to inpatient care. Ann Emerg Med. 2009;53(6):701-710.e4. https://pubmed.ncbi.nlm.nih.gov/18555560/. Accessed May 3, 2023.
  13. Wen LS, Espinola JA, Kosowsky JM, Camargo CA Jr. Do emergency department patients receive a pathological diagnosis? A nationally-representative sample. West J Emerg Med. 2015;16(1):50-54. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4307726/. Accessed May 3, 2023.
  14. Coiera EW, Jayasuriya RA, Hardy J, Bannan A, Thorpe MEC. Communication loads on clinical staff in the emergency department. Med J Aust. 2002;176(9):415-418. https://pubmed.ncbi.nlm.nih.gov/12056992/. Accessed May 3, 2023.
  15. Graber M. Diagnostic errors in medicine: a case of neglect. Jt Comm J Qual Patient Saf. 2005;31(2):106-113. https://pubmed.ncbi.nlm.nih.gov/15791770/. Accessed May 3, 2023.
  16. Kovacs G, Croskerry P. Clinical decision making: an emergency medicine perspective. Acad Emerg Med. 1999;6(9):947-952. https://pubmed.ncbi.nlm.nih.gov/10490259/. Accessed May 3, 2023.
  17. Engebretsen E, Heggen K, Wieringa S, Greenhalgh T. Uncertainty and objectivity in clinical decision making: a clinical case in emergency medicine. Med Health Care Philos. 2016;19(4):595-603. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5088215/. Accessed May 3, 2023.
  18. Wears RL, Nemeth CP. Replacing hindsight with insight: toward better understanding of diagnostic failures. Ann Emerg Med. 2007;49(2):206-209. doi: 10.1016/j.annemergmed.2006.08.027.
  19. Kachalia A, Gandhi TK, Puopolo AL, Yoon C, Thomas EJ, Griffey R, Brennan TA, Studdert DM. Missed and delayed diagnoses in the emergency department: a study of closed malpractice claims from 4 liability insurers. Ann Emerg Med. 2007;49(2):196-205. https://pubmed.ncbi.nlm.nih.gov/16997424/. Accessed May 3, 2023.
  20. Hussain F, Cooper A, Carson-Stevens A, Donaldson L, Hibbert P, Hughes T, Edwards A. Diagnostic error in the emergency department: learning from national patient safety incident report analysis. BMC Emerg Med. 2019;19(1):77. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6894198/. Accessed May 3, 2023.
  21. Green SM, Martinez-Rumayor A, Gregory SA, Baggish AL, O'Donoghue ML, Green JA, Lewandrowski KB, Januzzi JL Jr. Clinical uncertainty, diagnostic accuracy, and outcomes in emergency department patients presenting with dyspnea. Arch Intern Med. 2008;168(7):741-748. https://pubmed.ncbi.nlm.nih.gov/18413557/. Accessed May 3, 2023.
  22. Beach C, Cheung DS, Apker J, Horwitz LI, Howell EE, O’Leary KJ, Patterson ES, Schuur JD, Wears R, Williams M. Improving interunit transitions of care between emergency physicians and hospital medicine physicians: a conceptual approach. Acad Emerg Med. 2012;19(10):1188-1195. https://pubmed.ncbi.nlm.nih.gov/23035952/. Accessed May 3, 2023.
  23. Croskerry P. The cognitive imperative: thinking about how we think. Acad Emerg Med. 2000;7(11):1223-1231. https://pubmed.ncbi.nlm.nih.gov/11073470/. Accessed May 3, 2023.
  24. Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003;78(8):775-780. https://pubmed.ncbi.nlm.nih.gov/12915363/. Accessed May 3, 2023.
  25. Sorrentino P. Use of failure mode and effects analysis to improve emergency department handoff processes. Clin Nurse Spec. 2016;30(1):28-37. https://pubmed.ncbi.nlm.nih.gov/26626745/. Accessed May 3, 2023.
  26. Smith CJ, Britigan DH, Lyden E, Anderson N, Welniak TJ, Wadman MC. Interunit handoffs from emergency department to inpatient care: a cross-sectional survey of physicians at a university medical center. J Hosp Med. 2015;10(11):711-717. doi: 10.1002/jhm.2431. Accessed May 3, 2023.
  27. Apker J, Mallak LA, Applegate EB 3rd, Gibson SC, Ham JJ, Johnson NA, Street RL Jr. Exploring emergency physician-hospitalist handoff interactions: development of the Handoff Communication Assessment. Ann Emerg Med. 2010;55(2):161-170. https://pubmed.ncbi.nlm.nih.gov/19944486/. Accessed May 3, 2023.
  28. Slovis BH, McCarthy DM, Nord G, Doty AM, Piserchia K, Rising KL. Identifying emergency department symptom-based diagnoses with the Unified Medical Language System. West J Emerg Med. 2019;20(6):910-917. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6860381/. Accessed May 3, 2023.
  29. Espinosa JA, Nolan TW. Reducing errors made by emergency physicians in interpreting radiographs: longitudinal study. BMJ. 2000;320(7237):737-740. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC27314/. Accessed May 3, 2023.
  30. Agency for Healthcare Research and Quality. Calibrate Dx: A Resource To Improve Diagnostic Decisions. AHRQ Publication No. 22(23)-0047-2-EF. https://www.ahrq.gov/patient-safety/settings/multiple/calibrate-dx.html. Accessed May 3, 2023.
  31. Rising KL, Powell RE, Cameron KA, Salzman DH, Papanagnou D, Doty AMB, Latimer L, Piserchia K, McGaghie WC, McCarthy DM. Development of the Uncertainty Communication Checklist: a patient-centered approach to patient discharge from the emergency department. Acad Med. 2020;95(7):1026-1034. https://pubmed.ncbi.nlm.nih.gov/32101919/. Accessed May 3, 2023.
  32. Rising KL, Papanagnou D, McCarthy D, Gentsch A, Powell R. Emergency medicine resident perceptions about the need for increased training in communicating diagnostic uncertainty. Cureus. 2018;10(1):e2088. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5858850/. Accessed May 3, 2023.
  33. Bhise V, Meyer AND, Menon S, Singhal G, Street RL, Giardina TD, Singh H. Patient perspectives on how physicians communicate diagnostic uncertainty: an experimental vignette study. Int J Qual Health Care. 2018;30(1):2-8. https://pubmed.ncbi.nlm.nih.gov/29329438/. Accessed May 3, 2023.
  34. Meyer AND, Giardina TD, Khanna A, Bhise V, Singhal GR, Street RL, Singh H. Pediatric clinician perspectives on communicating diagnostic uncertainty. Int J Qual Health Care. 2019;31(9):G107-G112. https://pubmed.ncbi.nlm.nih.gov/31322679/. Accessed May 3, 2023.
  35. Politi MC, Clark MA, Ombao H, Légaré F. The impact of physicians’ reactions to uncertainty on patients’ decision satisfaction. J Eval Clin Pract. 2011;17(4):575-578. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2978752/. Accessed May 3, 2023.
  36. Vidyarthi AR, Arora V, Schnipper JL, Wall SD, Wachter RM. Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out. J Hosp Med. 2006;1(4):257-266. https://pubmed.ncbi.nlm.nih.gov/17219508/. Accessed May 3, 2023.
  37. Arora V, Johnson J, Lovinger D, Humphrey HJ, Meltzer DO. Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis. Qual Saf Health Care. 2005;14(6):401-407. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1744089/.
  38. Arora V, Johnson J. A model for building a standardized hand-off protocol. Jt Comm J Qual Patient Saf. 2006;32(11):646-655. https://pubmed.ncbi.nlm.nih.gov/17120925/. Accessed May 3, 2023.
  39. Arora VM, Johnson JK, Meltzer DO, Humphrey HJ. A theoretical framework and competency-based approach to improving handoffs. Qual Saf Health Care. 2008;17(1):11-14. https://pubmed.ncbi.nlm.nih.gov/18245213/. Accessed May 3, 2023.
  40. Arora VM, Manjarrez E, Dressler DD, Basaviah P, Halasyamani L, Kripalani S. Hospitalist handoffs: a systematic review and task force recommendations. J Hosp Med. 2009;4(7):433-440. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3575739/. Accessed May 3, 2023.
  41. Philibert I. Use of strategies from high-reliability organisations to the patient hand-off by resident physicians: practical implications. Qual Saf Health Care. 2009;18(4):261-266. https://pubmed.ncbi.nlm.nih.gov/19651928/. Accessed May 3, 2023.
  42. Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care. 2004;13 Suppl 1:i85-i90. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1765783/. Accessed May 3, 2023.
  43. Sanchez LD, Chiu DT, Nathanson L, Horng S, Wolfe RE, Zeidel ML, Boyd K, Tibbles C, Calder S, Dufresne J, Yang JJ. A model for electronic handoff between the emergency department and inpatient units. J Emerg Med. 2017;53(1):142-150. https://pubmed.ncbi.nlm.nih.gov/28506546/. Accessed May 3, 2023,
  44. Singleton JM, Sanchez LD, Masser BA, Reich B. Efficiency of electronic signout for ED-to-inpatient admission at a non-teaching hospital. Intern Emerg Med. 2018;13(7):1105-1110. doi: 10.1007/s11739-018-1816-z. Accessed May 3, 2023.
  45. Gonzalo JD, Yang JJ, Stuckey HL, Fischer CM, Sanchez LD, Herzig SJ. Patient care transitions from the emergency department to the medicine ward: evaluation of a standardized electronic signout tool. Int J Qual Health Care. 2014;26(4):337-347. https://pubmed.ncbi.nlm.nih.gov/24737836/. Accessed May 3, 2023.
  46. Nelson P, Bell AJ, Nathanson L, Sanchez LD, Fisher J, Anderson PD. Ethnographic analysis on the use of the electronic medical record for clinical handoff. Intern Emerg Med. 2017;12(8):1265-1272. doi: 10.1007/s11739-016-1567-7. Accessed May 3, 2023.
  47. Lee S, Jordan J, Hern HG, Kessler C, Promes S, Krzyzaniak S, Gallahue F, Stettner T, Druck J. Transition of care practices from emergency department to inpatient: survey data and development of algorithm. West J Emerg Med. 2017;18(1):86-92. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5226771/. Accessed May 3, 2023.
  48. Horwitz LI, Parwani V, Shah NR, Schuur JD, Meredith T, Jenq GY, Kulkarni RG. Evaluation of an asynchronous physician voicemail sign-out for emergency department admissions. Ann Emerg Med. 2009;54(3):368-378. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2764361/. Accessed May 3, 2023.
  49. Gonzalez CE, Brito-Dellan N, Banala SR, Rubio D, Ait Aiss M, Rice TW, Chen K, Bodurka DC, Escalante CP. Handoff tool enabling standardized transitions between the emergency department and the hospitalist inpatient service at a major cancer center. Am J Med Qual. 2018;33(6):629-636. https://pubmed.ncbi.nlm.nih.gov/29779398/. Accessed May 3, 2023.
  50. Smith CJ, Buzalko RJ, Anderson N, Michalski J, Warchol J, Ducey S, Branecki CE. Evaluation of a novel handoff communication strategy for patients admitted from the emergency department. West J Emerg Med. 2018;19(2):372-379. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5851513/. Accessed May 3, 2023.
  51. Salwei ME, Hoonakker P, Carayon P, Wiegmann D, Pulia M, Patterson BW. Usability of a human factors-based clinical decision support in the emergency department: lessons learned for design and implementation. Hum Factors. Published online April 14, 2022:187208221078625. https://pubmed.ncbi.nlm.nih.gov/35420923/. Accessed May 3, 2023.
  52. Strauss AT, Morgan C, El Khuri C, Slogeris B, Smith AG, Klein E, Toerper M, DeAngelo A, Debraine A, Peterson S, Gurses AP, Levin S, Hinson J. A patient outcomes-driven feedback platform for emergency medicine clinicians: human-centered design and usability evaluation of Linking Outcomes Of Patients (LOOP). JMIR Hum Factors. 2022;9(1):e30130. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8987968/. Accessed May 3, 2023.
  53. Liberman AL, Newman-Toker DE. Symptom-Disease Pair Analysis of Diagnostic Error (SPADE): a conceptual framework and methodological approach for unearthing misdiagnosis-related harms using big data. BMJ Qual Saf. 2018;27(7):557-566. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6049698/. Accessed May 3, 2023.
  54. Lyons PG, Fernando SM. On baseball, counterfactuals, and measuring care delivery performance at the emergency department-intensive care unit interface. Ann Am Thorac Soc. 2020;17(12):1532-1534. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7706602/. Accesseed May 3, 2023.
  55. Lyons PG, Arora VM, Farnan JM. Adverse events and near-misses relating to intensive care unit–ward transfer: a qualitative analysis of resident perceptions. Ann Am Thorac Soc. 2016;13(4):570-572. https://www.atsjournals.org/doi/10.1513/AnnalsATS.201512-789LE. Accessed May 3, 2023.
  56. Hosein FS, Bobrovitz N, Berthelot S, Zygun D, Ghali WA, Stelfox HT. A systematic review of tools for predicting severe adverse events following patient discharge from intensive care units. Crit Care. 2013;17(3):R102. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4056089/. Accessed May 3, 2023.
  57. Santhosh L, Lyons PG, Rojas JC, Ciesielski TM, Beach S, Farnan JM, Arora V. Characterising ICU–ward handoffs at three academic medical centres: process and perceptions. BMJ Qual Saf. 2019;28(8):627-634. https://pubmed.ncbi.nlm.nih.gov/30636201/. Accessed May 3, 2023.
  58. Gal DB, Han B, Longhurst C, Scheinker D, Shin AY. Quantifying electronic health record data: a potential risk for cognitive overload. Hosp Pediatr. 2021;11(2):175-178. https://publications.aap.org/hospitalpediatrics/article/11/2/175/26115/Quantifying-Electronic-Health-Record-Data-A. Accessed May 3, 2023.
  59. Dunlop M, Schwartzstein RM. Reducing diagnostic error in the intensive care unit. engaging uncertainty when teaching clinical reasoning. ATS Sch. 2020;1(4):364-371. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8015765/. Accessed May 3, 2023.
  60. Bergl PA, Nanchal RS, Singh H. Diagnostic error in the critically iii: defining the problem and exploring next steps to advance intensive care unit safety. Ann Am Thorac Soc. 2018;15(8):903-907. https://www.atsjournals.org/doi/10.1513/AnnalsATS.201801-068PS. Accessed May 3, 2023.
  61. Solet DJ, Norvell JM, Rutan GH, Frankel RM. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med. 2005;80(12):1094-1099. https://pubmed.ncbi.nlm.nih.gov/16306279/. Accessed May 3, 2023.
  62. Kitch BT, Cooper JB, Zapol WM, Marder JE, Karson A, Hutter M, Campbell EG. Handoffs causing patient harm: a survey of medical and surgical house staff. Jt Comm J Qual Patient Saf. 2008;34(10):563-570. https://pubmed.ncbi.nlm.nih.gov/18947116/. Accessed May 3, 2023.
  63. Sauro KM, Soo A, de Grood C, Yang MMH, Wierstra B, Benoit L, Couillard P, Lamontagne F, Turgeon AF, Forster AJ, Fowler RA, Dodek PM, Bagshaw SM, Stelfox HT. Adverse events after transition from ICU to hospital ward: a multicenter cohort study. Crit Care Med. 2020;48(7):946-953. https://pubmed.ncbi.nlm.nih.gov/32317594/. Accessed May 3, 2023.
  64. Rojas JC, Lyons PG, Jiang T, Kilaru M, McCauley L, Picart J, Carey KA, Edelson DP, Arora VM, Churpek MM. Accuracy of clinicians’ ability to predict the need for intensive care unit readmission. Ann Am Thorac Soc. 2020;17(7):847-853. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7328179/. Accessed May 3, 2023.
  65. Abraham J, Nguyen V, Almoosa KF, Patel B, Patel VL. Falling through the cracks: information breakdowns in critical care handoff communication. AMIA Annu Symp Proc. 2011;2011:28-37. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3243259/. Accessed May 3, 2023.
  66. Zinn C. 14,000 preventable deaths in Australian hospitals. BMJ. 1995;310(6993):1487. https://pubmed.ncbi.nlm.nih.gov/7787586/. Accessed May 3, 2023.
  67. Ågård AS, Hofhuis JGM, Koopmans M, Gerritsen RT, Spronk PE, Engelberg RA, Randall Curtis J, Zijlstra JG, Jensen HI. Identifying improvement opportunities for patient- and family-centered care in the ICU: using qualitative methods to understand family perspectives. J Crit Care. 2019;49:33-37. https://pubmed.ncbi.nlm.nih.gov/30359923/. Accessed May 3, 2023.
  68. Stelfox HT, Lane D, Boyd JM, Taylor S, Perrier L, Straus S, Zygun D, Zuege DJ. A scoping review of patient discharge from intensive care: opportunities and tools to improve care. Chest. 2015;147(2):317-327. https://pubmed.ncbi.nlm.nih.gov/25210942/. Accessed May 3, 2023.
  69. Plotnikoff KM, Krewulak KD, Hernández L, Spence K, Foster N, Longmore S, Straus SE, Niven DJ, Parsons Leigh J, Stelfox HT, Fiest KM. Patient discharge from intensive care: an updated scoping review to identify tools and practices to inform high-quality care. Crit Care. 2021;25(1):438. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8684123/. Accessed May 3, 2023.
  70. Santhosh L, Rojas JC, Garcia B, Thomashow M, Lyons PG. Cocreating the ICU-PAUSE tool for intensive care unit-ward transitions. ATS Sch. 2022;3(2):312-323. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9341494/. Accessed May 3, 2023.
  71. Fukui E, Lyons PG, Harris E, McCune EK, Rojas JC, Santhosh L. Improving communication in intensive care unit to ward transitions: protocol for multisite national implementation of the ICU-PAUSE handoff tool. JMIR Res Protoc. 2023 Feb 6;12:e40918.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9941899/. Accessed May 3, 2023.
  72. Massa S, Wu J, Wang C, Peifer H, Lane-Fall MB. Interprofessional training and communication practices among clinicians in the postoperative ICU handoff. Jt Comm J Qual Patient Saf. 2021;47(4):242-249. https://pubmed.ncbi.nlm.nih.gov/33451897/. Accessed May 4, 2023.
  73. Raiten JM, Lane-Fall M, Gutsche JT, Kohl BA, Fabbro M, Sophocles A, Chern SY, Al-Ghofaily L, Augoustides JG. Transition of care in the cardiothoracic intensive care unit: a review of handoffs in perioperative cardiothoracic and vascular practice. J Cardiothorac Vasc Anesth. 2015;29(4):1089-1095. https://pubmed.ncbi.nlm.nih.gov/25910986/. Accessed May 4, 2023.
  74. Greenberg CC, Regenbogen SE, Studdert DM, Lipsitz SR, Rogers SO, Zinner MJ, Gawande AA. Patterns of communication breakdowns resulting in injury to surgical patients. J Am Coll Surg. 2007;204(4):533-540. https://pubmed.ncbi.nlm.nih.gov/17382211/. Accessed May 4, 2023.
  75. Lane-Fall MB, Christakos A, Russell GC, Hose BZ, Dauer ED, Greilich PE, Hong Mershon B, Potestio CP, Pukenas EW, Kimberly JR, Stephens-Shields AJ, Trotta RL, Beidas RS, Bass EJ. Handoffs and transitions in critical care—understanding scalability: study protocol for a multicenter stepped wedge type 2 hybrid effectiveness-implementation trial. Implement Sci. 2021;16(1):1-13. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8204062/. Accessed May 4, 2023.
  76. Klein G. Naturalistic decision making. Hum Factors. 2008;50(3):456-460. doi: 10.1518/001872008X288385. Accessed May 3, 2023.
  77. Antonacci AC, Dechario SP, Antonacci C, Husk G, Patel V, Nicastro J, Coppa G, Jarrett M. Cognitive bias impact on management of postoperative complications, medical error, and standard of care. J Surg Res. 2021;258:47-53. https://pubmed.ncbi.nlm.nih.gov/32987224/. Accessed May 3, 2023.
  78. Stiegler MP, Neelankavil JP, Canales C, Dhillon A. Cognitive errors detected in anaesthesiology: a literature review and pilot study. Br J Anaesth. 2012;108(2):229-235. https://pubmed.ncbi.nlm.nih.gov/22157846/. Accessed May 4, 2023.
  79. Antonacci AC, Dechario S, Husk G, Stoffels G. Surgical judgment and mortality: analysis by a critique algorithm-based database and morbidity review. Acad Surg Cong Abstr Arch. 2019 Jan 31. https://www.asc-abstracts.org/abs2019/16-17-surgical-judgment-and-mortality-analysis-by-a-critique-algorithm-based-database-and-morbidity-review/. Accessed May 16, 2023.
  80. Abraham J, Meng A, Tripathy S, Avidan MS, Kannampallil T. Systematic review and meta-analysis of interventions for operating room to intensive care unit handoffs. BMJ Qual Saf. 2021;30(6):513-524. https://pubmed.ncbi.nlm.nih.gov/33563791/. Accessed May 4, 2023.
  81. Bougeard AM, Watkins B. Transitions of care in the perioperative period - a review. Clin Med. 2019;19(6):446-449. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6899237/. Accessed May 3, 2023.
  82. Lane-Fall MB, Pascual JL, Peifer HG, Di Taranti LJ, Collard ML, Jablonski J, Gutsche JT, Halpern SD, Barg FK, Fleisher LA; HATRICC study team (Kimberly Allen, BSN, RN; Mark Barry, MD; Sruthi Buddai, BA; Tyler Chavez, BA; Mahrukh Choudhary, BA; Della George; Megan Linehan, DO; Enrique Torres Hernandez; Jerome Watts, BA. A partially structured postoperative handoff protocol improves communication in 2 mixed surgical intensive care units: findings from the Handoffs and Transitions in Critical Care (HATRICC) Prospective Cohort Study. Ann Surg. 2020;271(3):484-493. https://pubmed.ncbi.nlm.nih.gov/30499797/. Accessed May 4, 2023.
  83. Abraham J, King CR, Meng A. Ascertaining design requirements for postoperative care transition interventions. Appl Clin Inform. 2021;12(1):107-115. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7904383/. Accessed May 4, 2023.
  84. Lane-Fall MB, Cobb BT, Cené CW, Beidas RS. Implementation science in perioperative care. Anesthesiol Clin. 2018;36(1):1-15. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5828037/. Accessed May 4, 2023.
  85. Zjadewicz K, Deemer KS, Coulthard J, Doig CJ, Boiteau PJ. Identifying what is known about improving operating room to intensive care handovers: a scoping review. Am J Med Qual. 2018;33(5):540-548. https://pubmed.ncbi.nlm.nih.gov/29374964/. Accessed May 4, 2023.
  86. Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003;18(8):646-651. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1494907/. Accessed May 4, 2023.
  87. Joint Commission on the Accreditation of Healthcare Organizations. Standard IM.6.10, EP 7. http://www.jointcommission.org/. Accessed May 3, 2023.
  88. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138(3):161-167. doi: 10.7326/0003-4819-138-3-200302040-00007. Accessed May 4, 2023.
  89. Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297(8):831-841. https://pubmed.ncbi.nlm.nih.gov/17327525/. Accessed May 4, 2023.
  90. Hauschildt KE, Hechtman RK, Prescott HC, Iwashyna TJ. Hospital discharge summaries are insufficient following ICU stays: a qualitative study. Crit Care Explor. 2022;4(6):e0715. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9187199/. Accessed May 4, 2023.
  91. Graham KL, Auerbach AD, Schnipper JL, Flanders SA, Kim CS, Robinson EJ, Ruhnke GW, Thomas LR, Kripalani S, Vasilevskis EE, Fletcher GS, Sehgal NJ, Lindenauer PK, Williams MV, Metlay JP, Davis RB, Yang J, Marcantonio ER, Herzig SJ. Preventability of early versus late hospital readmissions in a national cohort of general medicine patients. Ann Intern Med. 2018;168(11):766-774. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6247894/. Accessed May 4, 2023.
  92. Raffel KE, Kantor MA, Barish P, Esmaili A, Lim H, Xue F, Ranji SR. Prevalence and characterisation of diagnostic error among 7-day all-cause hospital medicine readmissions: a retrospective cohort study. BMJ Qual Saf. 2020;29(12):971-979. https://pubmed.ncbi.nlm.nih.gov/32753409/. Accessed May 4, 2023.
  93. Agency for Healthcare Research and Quality. Guide to Patient and Family Engagement in Hospital Quality and Safety. Strategy 4: Care Transitions From Hospital to Home: IDEAL Discharge Planning.  https://www.ahrq.gov/patient-safety/patients-families/engagingfamilies/strategy4/index.html. Accessed May 3, 2023.
  94. Agency for Healthcare Research and Quality. Guide to Improving Patient Safety in Primary Care Settings by Engaging Patients and Families. Warm Handoff Plus. https://www.ahrq.gov/patient-safety/reports/engage/warmhandoff.html. Accessed May 3, 2023.
  95. Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med. 2007;2(5):314-323. doi: 10.1002/jhm.228. Accessed May 4, 2023.
  96. Smith CJ, Beachy M, Vasey A, Langenhan T, Shiffermiller J. Evaluation of an enhanced discharge summary template: building a better handoff document. J Clin Outcomes Manag. 2017;24(12). https://cdn.mdedge.com/files/s3fs-public/Document/November-2017/JCOM02412542.PDF. Accessed May 3, 2023.
  97. O’Leary KJ, Liebovitz DM, Feinglass J, Liss DT, Evans DB, Kulkarni N, Landler MP, Baker DW. Creating a better discharge summary: improvement in quality and timeliness using an electronic discharge summary. J Hosp Med. 2009;4(4):219-225. https://pubmed.ncbi.nlm.nih.gov/19267397/. Accessed May 4, 2023.
  98. Kantor MA, Evans KH, Shieh L. Pending studies at hospital discharge: a pre-post analysis of an electronic medical record tool to improve communication at hospital discharge. J Gen Intern Med. 2015;30(3):312-318. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4351274/. Accessed May 4, 2023.
  99. Whitehead NS, Williams L, Meleth S, Kennedy S, Epner P, Singh H, Wooldridge K, Dalal AK, Walz SE, Lorey T, Graber ML. Interventions to improve follow-up of laboratory test results pending at discharge: a systematic review. J Hosp Med. 2018;13(9):631-636. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9491200/. Accessed May 4, 2023.
  100. Dalal AK, Roy CL, Poon EG, Williams DH, Nolido N, Yoon C, Budris J, Gandhi T, Bates DW, Schnipper JL. Impact of an automated email notification system for results of tests pending at discharge: a cluster-randomized controlled trial. J Am Med Inform Assoc. 2014;21(3):473-480. https://pubmed.ncbi.nlm.nih.gov/24154834/. Accessed May 4, 2023.
  101. Graber ML, Kissam S, Payne VL, Meyer AN, Sorensen A, Lenfestey N, Tant E, Henriksen K, Labresh K, Singh H. Cognitive interventions to reduce diagnostic error: a narrative review. BMJ Qual Saf. 2012;21(7):535-557. https://pubmed.ncbi.nlm.nih.gov/22543420/. Accessed May 4, 2023.
  102. Huang GC, Kriegel G, Wheaton C, Sternberg S, Sands K, Richards J, Johnston K, Aronson M. Implementation of diagnostic pauses in the ambulatory setting. BMJ Qual Saf. 2018;27(6):492-497. https://pubmed.ncbi.nlm.nih.gov/29306903/. Accessed May 4, 2023.
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Internet Citation: References. Content last reviewed June 2023. Agency for Healthcare Research and Quality, Rockville, MD.
https://www.ahrq.gov/diagnostic-safety/resources/issue-briefs/dxsafety-care-transitions7.html

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