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Buitrago I, Seidl KL, Gingold DB, et al. J Healthc Qual. 2022;44:169-177.
Reducing hospital 30-day readmissions is seen as a way to improve safety and reduce costs. Baltimore City mobile integrated health and community paramedicine (MIH-CP) was designed to improve transitional care from hospital to home. After one year in operation, MIH-CP performed a chart review to determine causes of readmission among patients in the program. Root cause analysis indicated that at least one social determinant of health (e.g., health literacy) played a role in preventable readmissions; the program was modified to improve transitional care.
Holmes J, Chipman M, Barbour T, et al. Jt Comm J Qual Patient Saf. 2022;48:12-24.
Air medical transport carries unique patient safety risks. In this study, researchers used simulation training and healthcare failure mode and effect analysis (HFMEA) to identify latent safety threats related to patient transport via helicopter. This approach identified 31 latent safety threats (18 were deemed critical) related to care coordination, facilities, equipment, and devices.
Alabdali A, Fisher JD, Trivedy C, et al. Air Med J. 2017;36:116-121.
Interfacility transport of critically ill patients may be performed by physician-led teams or by paramedics without direct physician involvement. This systematic review attempted to determine if transport by paramedics alone was safe for patients, but researchers found only a small number of studies with limited characterization of the types of adverse events encountered in this situation.
Balka E, Tolar M, Coates S, et al. Int J Med Inform. 2013;82:e345-57.
This ethnographic case study explored patient handoffs across different situations, including pre-hospital and primary care settings. These analyses emphasize numerous contextual issues that need be considered when creating computerized systems to support handoffs.
Dawson S, King L, Grantham H. Emerg Med Australas. 2015;25:393-405.
Handoffs between care settings can lead to adverse events. This literature review analyzed 17 studies of handoffs between prehospital first responders and emergency department (ED) staff. Safety gaps detected included communication barriers, lack of a structured communication tool, and unclear identification of the receiving clinical staff. The authors suggest that a structured handoff tool could improve first responder–ED handoffs. A past AHRQ WebM&M commentary discussed communication failures between providers and highlighted a need for standard handoff protocols.

Brice JH, Patterson PD, eds. Prehosp Emerg Care. 2012;16:1-108.  

This special issue contains articles exploring safety improvement efforts in emergency medical services.
Gillman L, Leslie G, Williams T, et al. Emerg Med J. 2006;23:858-61.
This study evaluated nearly 300 adverse events that occurred during intrahospital transport, noting that equipment problems and hypothermia were the most common. Investigators combined 6 months of prospective observation with retrospective chart review to characterize the type and nature of events recorded for patients admitted to the intensive care unit from the emergency department. While the overall rates were lower than reported in past research, the authors advocate for using their findings as benchmarks: an adverse event rate of 22 of 100 transfers and 38 of 100 delays in transfer. A case commentary on Agency for Healthcare Research and Quality (AHRQ) WebM&M discusses the issue of intrahospital transport with suggestions for improving the safety of this poorly studied process.