• 1
    Cook RI, Render M, Woods DD. Gaps in the continuity of care and progress on patient safety. BMJ. 2000; 320: 791794.
  • 2
    Bull MJ, Hansen HE, Gross CR. Predictors of elder and family caregiver satisfaction with discharge planning. J Cardiovasc Nurs. 2000; 14: 7687.
  • 3
    Naylor MD, Brooten D, Campbell R, et al. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999; 281: 613620.
  • 4
    Forster AJ, Murff HJ, Peterson JF, et al. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003; 138: 161167.
  • 5
    Roy C, Poon EG, Karson AS, et al. Patient safety concerns arising from test results that return after hospital discharge. Ann Intern Med. 2005; 143: 121128.
  • 6
    Neale G, Woloshynowych M, Vincent C. Exploring the causes of adverse events in NHS hospital practice. J. R. Soc Med. 2001; 94: 553.
  • 7
    van Walraven C, Seth R, Austin PC, Laupacis A. Effect of discharge summary availability during the post-discharge visits on hospital readmission. J Gen Intern Med. 2002; 17: 186192.
  • 8
    Martens KH. An ethnographic study of the process of medication discharge education (MDE). J Adv Nurs. 1998; 27: 341348.
  • 9
    Cleary PD. A hospitalization from hell: a patient's perspective on quality. Ann Intern Med. 2003; 138: 3339.
  • 10
    Demlo LK, Campbell PM. Improving discharge data: lessons from the National Hospital Discharge Survey. Med Care 1981; 19: 10301040.
  • 11
    Felden JM, Scott S, Horne JG. An investigation of patient satisfaction following discharge after total hip replacement surgery. Orthop Nurs. 2003; 22: 429436.
  • 12
    Hickey ML, Kleefield SF, Pearson SD, et al. Payer-hospital collaboration to improve patient satisfaction with hospital discharge. Jt Comm J QuaI Improv. 1996; 22: 336344.
  • 13
    van Walraven C, Mamdani M, Fang J, Austin PC. Continuity of care and patient outcomes after hospital discharge. J Gen Intern Med. 2004; 19: 624631.
  • 14
    Resar R. Will, ideas, and execution: their role in reducing adverse medication events. J Pediatr. 2005; 147: 727728.
  • 15
    Resar R. Why we need to learn standardisation. Aust Fam Physician. 2005; 34(1-2): 6768.
  • 16
    Joint Commission on Accreditation of Healthcare Organizations. 2006 Critical Access Hospital and Hospital National Patient Safety Goals. Available at:
  • 17
    Census Bureau of Statistics, 2000.
  • 18
    Kucukarslan S, Peters M, Mlynarek, et al. Pharmacists on rounding teams reduce preventable adverse events in hospital general medicine units. Arch Intern Med. 2003; 163: 20142018.
  • 19
    Dudas V, Bookwalter T, Kerr K, et al. The impact of follow-up telephone calls to patients after hospitalization. Ann Intern Med. 2001; 111(9B): 26S30S.
  • 20
    Schnipper JL, Kirwin JL, Cotugno MC, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006; 166: 565571.
  • 21
    Lewis T. Using the NO TEARS tool for medication review. BMJ. 2004; 329: 434.
  • 22
    Manning DM. Toward safer warfarin therapy: does precise daily dosing improve INR control? Mayo Clinic Proc. 2002; 77: 873875.
  • 23
    Resar R. Institute for Healthcare Improvement, personal communication.
  • 24
    Institute of Medicine. KindigDA, editor. Health Literacy: A Prescription to End Confusion. Washington, DC: National Academies Press, 2004.
  • 25
    Manning DM, Keller AS, Frank DL. Independent Mobility Validation Exam (I-MOVE): a tool for periodic reassessment of fall-risk and discharge planning. Abstract and Poster presentation at SHM (formerly NAIP) 5th Annual Meeting, Philadelphia, PA, April 9, 2002.
  • 26
    Mathias S, Nayak US, Isaacs B. Balance in elderly patients: the “get-up-and-go” test. Arch Phys Med Rehabil. 1986; 67: 387389.
  • 27
    AMA, Council on Ethical and Judicial Affairs. Guidelines for appropriate use of “do-not-resuscitate” orders. JAMA. 1991; 265: 18681871.
  • 28
    van Walraven C, Weinberg AL. Quality assessment of a discharge summary system. CMAJ. 1995; 152: 14371442.
  • 29
    van Walraven C, Rokosh E. What is necessary for high-quality discharge summaries? Am J Med Qual. 1999. 14: 160169.
  • 30
    JCAHO Manual: Information Management (IM) 6.10 and Patient Care (PC) 15.30
  • 31
    Whitford K, Huddleston JM. Specific appointments after pneumonia hospitalization reduce readmissions. Abstract and Poster presentation at SHM (formerly NAIP) 5th Annual Meeting, Philadelphia, PA, April 9, 2002.