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Institute for Healthcare Improvement. 2009 -2013.
This Web site supports an initiative to reduce avoidable rehospitalizations by improving transitions in care and communication between multiple care sites. The program ran from May 2009 through June 2013.  
After several pediatric visits, parents of a newborn with low output and weight loss contact a lactation consultant, who discovered that ankyloglossia (tongue-tie) was preventing the infant from receiving adequate intake from breastfeeding.
Flabouris A, Runciman WB, Levings B. Anaesth Intensive Care. 2006;34:228-236.
The authors analyzed adverse events that occurred during out-of-hospital patient transfer. They found that 91% of reported failures were preventable and conclude that incident monitoring is an effective tool for safety improvement.
A woman with a fractured right foot receives spinal anesthesia and nearly has surgery for trimalleolar fracture and dislocation of the left ankle. Only immediately prior to surgery did the team realize that the x-ray was not hers.