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PSNet: Patient Safety Network
Newspaper/Magazine Article

Lessons learned from a death outside a hospital's doorstep.

Palmer J. Patient Saf Qual Healthc. May/June 2019.

Organizations must learn from adverse events to prevent similar incidents. Reporting on lessons to be learned from the cascade of failures connected with the preventable death of a patient during an acute asthma attack at the door of a hospital emergency department, this magazine article outlines the importance of effective signage, appropriate security staff placement, and acceptance of the responsibility for failure.