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Effective integration of health information systems supports decision making and treatment coordination across practice settings. This report examines how gaps in information sharing can affect behavioral health care. The authors discuss the potential for diagnostic improvement through information system connections between primary care and behavioral health programs.

Surgical specimen and laboratory process problems can affect diagnosis. This publication examines factors that contribute to errors across the surgical pathology process and reviews strategies to reduce their impact on care. Chapters discuss areas of focus to encourage process improvement and error response, such as information technology, specimen tracking, root cause analysis, and disclosure.

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.

Although health information technology was implemented to improve safety, it has resulted in unintended consequences such as clinician burnout and perpetuation of incorrect information. This publication explores the barriers to achieving the interoperability needed to build a robust digital infrastructure that will seamlessly and reliably share information across the complex system of health care. The report advocates for adjusting purchasing behaviors to focus less on the price and features of each product and to instead look for interoperable technologies. The report outlines five action priorities to guide leadership decision-making around procurement, including championing systemwide interoperability and identifying goals and requirements. A PSNet interview discussed potential consequences of the digitization of health care.

While implementation of health information technology (IT) is widely recommended, research has raised the concern that it may lead to unintended consequences on patient safety. This draft report explores key recommendations for ensuring the safe use of health IT, such as the establishment of a "Health IT Safety Center" to test, disseminate, and promote assessment tools. The comment submission period is now closed.

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.

Following the implementation of a large clinical information communication technology project, this report identified interoperability and usability failures and noted medication ordering and management as particularly vulnerable to errors.

Part of a comprehensive electronic compilation on medical informatics, this series of papers examines topics surrounding the use of health information technology (HIT) to detect, report, and learn from adverse events.

This government report analyzes the National Health Service's efforts to enhance patient safety and recommends improving certain areas, such as adopting technology, analyzing failure, and ensuring both practitioner education and adequate staffing.

This report compiles public and private data to provide insight into the quality and safety of patient care in Australian hospitals.

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.

This report analyzes an incident of medication error that led to a patient's death, discusses the subsequent actions taken by the health board, and calls for a coordinated approach to medication reconciliation in New Zealand.