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London, UK: Parliamentary and Health Service Ombudsman; 2021. ISBN 9781528627016. 

Lack of appropriate follow up of diagnostic imaging can result in care delays, patient harm, and death. This report summarizes an investigation of 25 imaging failures in the British National Health Service (NHS). The analysis identified communication and coordination issues resulting in lack of action and reporting of unanticipated findings to properly advance care. Recommendations to improve imaging in the NHS include use of previous analyses to enhance learning from failure.

Kirkup B. London, England: Crown Copyright; 2020. ISBN 9781528622714.

Missed diagnosis of a dangerous condition in utero, treatment errors, lack of response to concerns raised, and inadequate clinician expertise were among the contributing factors identified in this analysis of the death of a special needs infant at home. The 12 recommendations stemming from the investigation include improvements in disclosure support, clinician communication across facilities, and assignment of accountability when false and misleading statements are made during investigations.

de Bienassis K, Llena-Nozal A, Klazinga N for the Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2020. OECD Health Working Papers, No. 121.

Adverse events in long term care facilities are acerbated due to staffing, training and financial challenges. This report examined the costs of avoidable problems in long term care and suggests prevention strategies that center on workforce skill development and safety culture improvement.
Rockville, MD: Agency for Healthcare Research and Quality; December 6, 2019. PA-20-068.
Communication during patient transitions carries the potential for mistakes that can result in patient harm. This program (funding) announcement will support the testing of interventions to improve communication and coordination during care transitions within and between a variety of care environments. Applicants are encouraged to incorporate a care transitions model such as Project RED into their research design. Applications are reviewed three times per year- February 5, June 5, and October 5, through 2022