Dahlberg B. Kaiser Health News. September 29, 2020.
This story discusses failures related emergency psychiatric assessment, including premature discharge, implicit bias, patient management discontinuity and inappropriate physical restraint that contributed to the death of a patient at risk for suicide.
System weaknesses are often at the root of never events. This news story discusses the suicide of a concussed woman whose care failed due to gaps in team communication, discharge and transition practices.
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