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Safe Handoffs at Change of Shift: Nurse Knowledge Exchange

The Joint Commission reports that approximately 70% of sentinel events are communication handoff issues. Handoffs are among the most hazardous situations in the inpatient care setting. This program will help you set up a nurse information exchange process for shift changes that helps to meet the National Patient Safety Goal 2E - Implement a standardized approach to hand off communications, including an opportunity to ask and respond to questions.

This program will help hospitals and providers understand the successful four step change of shift handoff process used by nurses at Kaiser Permanente, known as Nurse Knowledge Exchange.

Program announcement
Program Audio CD and Powerpoint Presentation

Patient Med List

You may update your Med List electronically.
Click here to download a free Patient Med List.

For more information, contact MA Coalition at 781-262-6082 or email macoalition@macoalition.org

Reconciling Medications

Safe Practice Recommendations to Reconcile Medications
Implementation Guide for Safe Practices (A Resource Book of Materials)
View Table of Contents

Communicating Critical Test Results

Safe Practice Recommendations to Communicate Critical Test Results
Implementation Guide for Safe Practices (A Resource Book of Materials)
View Table of Contents

When Things Go Wrong:  Responding to Adverse Events

A Consensus Statement of the Harvard Hospitals

Prepared by physicians, nurses, risk managers, and patients from the Harvard teaching hospitals, the document attempts to summarize the current thinking about the best practices to follow when a patient suffers injury from medical treatment. Its objectives are to provide a deeper understanding of the issues involved to help hospitals and caregivers develop more effective policies for managing patients and caregivers following injury. The concepts and principles are supported by he Harvard teaching hospitals.

Published on the Massachusetts Coalition for the Prevention of Medical Errors web site with permission.

Guide for Patients: “Your Role in Safe Medication Use”


English
Online Version		 Consumer Guide

The Massachusetts Coalition for the Prevention of Medical Errors has developed a consumer guide that encourages patients to become "part of the health care team" along with their physicians, nurses, and pharmacists, to prevent medication mistakes. The guide was developed in conjunction with the Washington, D.C.-based Institute for Family-Centered Care and is based on input solicited from patients, families, and health care professionals. The brochure is also available in Spanish.

For more information, contact:
MA Coalition
Phone:  781-262-6080
Email:  macoalition@macoalition.org

Click here to download the brochure order form
Spanish
Online Version

Reporting Requirements

  • Reporting Requirements Across Agencies
  • The Coalition conducted an inventory of hospital reporting requirements across health care agencies. For each agency, the document identifies reportable incidents, incident specifics required when reporting, disclosable information, as well as confidentiality issues. The agencies presented include: Massachusetts Board of Registration in Medicine, Massachusetts Department of Public Health, Massachusetts Department of Mental Health, Massachusetts Office of the Chief Medical Examiner, JCAHO, CMS/LTC, and the FDA.
  • This document was revised April 2004. It is a working document that is subject to change. If you have comments or updates, contact Effie Brickman at 781-262-6082 ext. 185 or macoalition@macoalition.org.

Restraints and Seclusion

Reducing Medication Errors in Acute Care and Long Term Care Facilities

Patient Safety Tools
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