The PSNet Collection

Harm Caused by Delays in Transferring Patients to the Right Place of Care.

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Farnborough, UK: Healthcare Safety Investigation Branch; June 2022.

Handoffs between prehospital emergency medical services (EMS) providers and hospital emergency departments (EDs) can be suboptimal, which increases patient harm potential. This interim report examines National Health Service discharge delays. It suggests a systemic approach is needed to address flow and capacity factors that contribute to ineffective and unsafe interfacility discharge and transfer.

Unwell Women: Misdiagnosis and Myth in a Man-Made World.

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Cleghorn E. New York, NY: Dutton; 2021. ISBN: 9780593182956.

Women have been affected by implicit bias that undermines the safety of their care and trust in the medical system. This book shares the history anchoring the mindsets driving ineffective care for women and a discussion of the author’s long-term lupus misdiagnosis.

How medical jargon can make COVID health disparities even worse.

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Kritz F. Shots. National Public Radio; May 24, 2021.

Health literacy efforts address challenges related to both language and effective communication tactics. This story discussed how lack of language and information clarity reduced patient education effectiveness during the pandemic and highlights several efforts to address them including information product translation services.

Cancer diagnoses delayed among prisoners in Washington state.

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Medscape Medical News. May 12, 2021.

Delays and mistakes in health care for distinct patient populations hold improvement lessons for the broader system. This news story highlights problems in correctional system cancer diagnoses and treatment that may indicate other types of prison care delivery problems.

‘You’re going to release him when he was hurting himself?’

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Dahlberg B. Kaiser Health News. September 29, 2020.

This story discusses failures related emergency psychiatric assessment, including premature discharge, implicit bias, patient management discontinuity and inappropriate physical restraint that contributed to the death of a patient at risk for suicide.

Sent home to die.

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Waldman A, Kaplan J. ProPublica. 2020.

Hospitals have been deeply challenged to provide effective care during the COVID crisis. This article discusses how rationing and ineffective protection for families and patients may have contributed to preventable death and the spread of the virus in families due to unnecessary referrals of patients to home care and hospice.

Doctors turned my sister away; less than two years later she died of cervical cancer.

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Harvey-Jenner C. Cosmopolitan. August 27, 2020.

Implicit biases are known to impact effective diagnosis. This story highlights how dismissed concerns resulted in a delay in cancer diagnosis that contributed to the death of a young woman.

Inadequate Emergency Department Care and Physician Misconduct at the Washington DC VA Medical Center.

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Office of the Inspector General. Washington, DC: Department of Veterans Affairs; July 28, 2020. Report Number 19-07507-214.

Patient suicide is a never event. This report analyzes the death of a veteran after presenting at an emergency room with suicidal ideation. The analysis found lack of both suicide prevention policy adherence and appropriate assessment, as well as a lack concern for the patient’s condition contributed to the failure.

Fear of Covid-19 leads other patients to decline critical treatment.

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Hafner K. New York Times. 2020;May 25.

The uncertainties surrounding coronavirus transmission and treatment are causing patients with known conditions to forgo needed medical care. This article outlines how COVID-19 fear and anxiety are primary contributing factors in patient decisions to delay transplants and other necessary treatments.

As COVID-19 bears down, doctors confront difficult choices on elective surgeries.

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Alesse L, Dukakis A, Tatum S, Mosk M. ABC News. March 20, 2020.

Delays in elective surgery and other procedures have the potential to lessen safe patient care. This news story describes the decision-making dilemma for physicians to limit patient access to care during the COVID-19 pandemic. Their concern is that the delays have the potential to result in diagnostic and treatment service deviations that could result in harm.

A 25-year-old teacher died after waiting hours at the ER. She's not the only one who saw delays.

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Linnane R, Diedrich J. Milwaukee Journal Sentinel. February 25, 2020.

Delays in emergency room (ER) triage and assessment contribute to wide range of failures that degrade patient safety. This news story highlights the findings of a government report highlighting overcrowding and production pressures as factors resulting in the death of a patient waiting for care who initially presented at the ER with symptoms of heart attack.

Investigation into Detection of Retained Vaginal Swabs and Tampons Following Childbirth.

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Farnborough, UK; Healthcare Safety Investigation Branch; December 18, 2019.

Maternal care during and after childbirth is at risk for never events including retained foreign objects. This analysis of a sentinel event involving a retained surgical tampon after childbirth discusses communication, fatigue, and process factors that contributed to the incident. The report suggests improved handoffs as one improvement strategy.

The Caregiver Advise, Record, Enable (CARE) act.

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Anthony M. Home Healthc Now. 2018;36:69-70.

Home healthcare is an increasingly viable option for patients who requires the complex care skills of caregivers. This commentary discusses the Caregiver Advise, Record, Enable (CARE) Act as a policy lever to ensure family caregivers have the training they need to provide safe care.

Ambulance crew in Chicago got lost trying to find hospital.

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News Services. Washington Post. October 25, 2007

An emergency crew from a suburb failed to efficiently transport a marathon runner in cardiac arrest to the nearest emergency room in central Chicago.

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