Lack of accountability for systemic contributions to failure degrades efforts to generate improvement. This report discusses gaps in the British National Health Service patient safety culture. It calls for governmental oversight and commitment as the central activation lever necessary to achieve collective, coordinated effort and motivate large-scale action to support lasting change.

Gaps in patient information processes can result in missed care opportunities that contribute to harm. This report examines language discordance in National Health Service written scheduling communications and its contribution to patients being lost to follow up. The primary improvement recommendation is to enhance the ability of providers to recognize primary languages of patients and provide written instructions accordingly.

Programs are in place to address hospital discharge process gaps that contribute to readmissions. This report summarizes research on primary care perspectives on reducing readmissions. Interventions identified include automated alerting to primary care providers when patients are hospitalized and the patient-centered medical home model.

Transitions are known to be vulnerable to communication errors. This toolkit focuses on patient transitions between ambulatory care environments and encourages staff to engage patients and families in their care to prevent errors during care transitions.

Patient safety in ambulatory care is receiving increased attention. This guide includes case studies that explore how Open Notes, team-based care delivery, and patient and family advisory committees have shown promise as patient engagement and safety improvement mechanisms in primary care settings.

The AHRQ Health Literacy Universal Precautions Toolkit, 2nd edition, can help primary care practices implement improvement actions to reduce the complexity of health care, increase patient understanding of health information, and enhance support for patients of all health literacy levels.

This publication summarizes findings from 12 projects that explored how health information technology can enhance management and quality of care for patients with complex conditions in the ambulatory setting.

This series, developed in conjunction with the STAAR initiative, provides tactics and resources to improve transitions across various care settings.

This guide discusses the impact of poor communication on care transitions and describes tactics for improvement.

This report analyzed how medication information is shared among UK practices and patients after a hospital stay and found that 81% of general practices thought that patient information given to them from hospitals was incomplete or inaccurate.

This book provides an introduction to key patient safety topics and includes a set of 20 case studies to demonstrate opportunities for error prevention.

This report provides two example scenarios—inpatient medication reconciliation and medication management in ambulatory care—to explore how improved information exchange can support safe medication management.