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Harrisburg, PA: Patient Safety Authority. ISSN 2641-4716.

The Pennsylvania Patient Safety Authority is a long-established source of patient safety data analysis and application-focused commentary. Their publishing output aims to generate improvements in their state as well as throughout health care. This open-access publication replaces the quarterly Pennsylvania Patient Safety Advisory newsletter.

Deny, Dismiss, Dehumanise: What Happened When I Went to Hospital.

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Cullen A. Uitgeverij van Brug: The Hague, The Netherlands; 2019. ISBN: 9789065232236.

Patient stories offer important insights regarding the impact medical errors have on patients and their families. This book shares the author's experience with medical error and spotlights how lack of transparency in European health care can contribute to avoidable process failures that result in patient harm.

Maternal deaths at MetroWest hospital prompt state probes.

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Kowalczyk L.

Maternal death is a sentinel event. This news article reports on two incidents at one hospital that prompted investigations and describes strategies to improve maternal safety, including standardizing procedures and enhancing communication.

Healthcare professional and patient codesign and validation of a mechanism for service users to feedback patient safety experiences following a care transfer: a qualitative study.

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Scott J, Heavey E, Waring J, et al. BMJ Open. 2016;6:e011222.

Patients may provide a valuable perspective with regard to safety efforts. In this qualitative study, researchers developed and validated a survey for patients to provide feedback on safety issues about care transfers between different institutions. The authors suggest that further research is necessary to determine the usability of the survey and how best to use the patient feedback obtained.

Weak oversight allows lab failures to put patients at risk.

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Gabler E. Milwaukee Journal Sentinel. May 15, 2015.

Reporting on weaknesses in laboratory testing methods, this news article discusses patients' experiences with testing errors to illustrate how such failures can contribute to patient harm—such as missed or delayed diagnosis—and raises concerns about insufficient transparency, investigations, and regulations around laboratory facilities with poor processes.

Living with cancer: not talking about medical mistakes.

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Gubar S.

This newspaper article describes how surgical complications, health care–associated infections, and ineffective patient–provider communication contributed to a patient's experience with harm and suggests that transparency around the incident and preoperative patient briefings could have improved the situation.

Delivering results.

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Landro L. Wall Street Journal. March 28, 2011.

This newspaper article discusses how combining best practices in teamwork, simulation, and communication can improve patient safety during obstetric emergencies.

Alleged kidnapper agrees to extradition.

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Blaney B; Associated Press

This article reports on the abduction of a newborn by an individual masquerading as a hospital employee. Infant abduction is one of the patient safety "never events" defined by the National Quality Forum.

Three die at Vets Home after errors.

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Wolfe W. Star Tribune.

This article reports on three patient deaths due to errors at a state-owned nursing home for veterans.

Maternity ward at Highland under fire from patients.

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Vesely R. East Bay Times. December 28, 2006.

This article describes a variety of quality and safety problems in the labor and delivery ward at a large public hospital.

Survive your doctor.

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This series includes articles on "doorway diagnosis" (or a doctor's assessment of a patient before an exam begins), anesthesiologists addicted to painkillers, and medical mistakes in the emergency room.

Promoting collaboration and transparency in patient safety.

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Apold J, Daniels T, Sonneborn M. Jt Comm J Qual Patient Saf. 2006;32:672-675.

This article discusses the efforts of the Minnesota Alliance for Patient Safety to promote a culture of safety among the state's health care organizations.

Improving Patient Safety Through Simulation Research.

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This announcement describes the 19 projects funded by the Agency for Healthcare Research and Quality in 2006 that studies the potential of simulation to improve patient safety.

Inquiry into reporter's death finds multiple failures in care.

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This article reports on the investigation following the death of New York Times reporter David E. Rosenbaum. The investigation uncovered a range of failures in emergency care and is described in a report available via the link below.

Get me out alive.

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Feldman R

In this article, a nurse shares her firsthand account of what it was like to be a surgical patient and the surprising safety and quality shortcomings she encountered during her hospital stay.

The Patients' View: 2004 ISQSH National Survey.

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Dublin: Irish Society for Quality and Safety in Healthcare; 2004.

This report provides results from a 26-hospital survey investigating areas of service and care weakness in Irish hospitals. The research revealed problems related to information transfer, overwork, and lack of patient involvement in decision making about their care.

Ding-a-ling-a-ling: ambulances can be dangerous places.

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Meisel Z.

In this article, an emergency medicine physician describes the work environment of emergency medical technicians and paramedics and why it is prone to error.

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