Rates of Medical Errors and Preventable Adverse Events among Hospitalized Children Following Implementation of a Resident Handoff Bundle.¶
Starmer, A. J., Sectish, T. C., Simon, D. W., Keohane, C., McSweeney, M. E., Chung, E. Y., Yoon, C. S., et al. (2013). Rates of Medical Errors and Preventable Adverse Events among Hospitalized Children Following Implementation of a Resident Handoff Bundle. JAMA, 310(21), 2262-2270.
Cited by¶
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Primes¶
- Boundary State Loss
- In healthcare shift change, a nurse signs out a patient list through a structured handoff form that captures vitals, medications, and pending labs but not the gestalt of "this patient looks worse than her chart says"; adverse events spike at shift boundaries.
This sourceDocuments elevated adverse-event rates at shift-change handoffs and their reduction via a structured handoff bundle (I-PASS).
- In healthcare shift change, a nurse signs out a patient list through a structured handoff form that captures vitals, medications, and pending labs but not the gestalt of "this patient looks worse than her chart says"; adverse events spike at shift boundaries.
Verification¶
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