Safety through redundancy: a case study of in-hospital patient transfers.
Ong M-S, Coiera E. Safety through redundancy: a case study of in-hospital patient transfers. Qual Saf Health Care. 2010;19(5):e32. doi:10.1136/qshc.2009.035972.
This study examined in-hospital patient transfers and discovered poor compliance with existing safety steps designed to prevent errors. A past AHRQ WebM&M commentary discussed a death that resulted from unsafe intrahospital transport.