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Unlocking Solutions in Imaging: Working Together to Learn from Failings in the NHS.
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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.
    The Life and Death of Elizabeth Dixon: A Catalyst for Change.
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    • 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.
    The Economics of Patient Safety Part III: Long-term Care: Valuing Safety for the Long Haul.
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    • 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.
    Investigation into Detection of Retained Vaginal Swabs and Tampons Following Childbirth.
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    • Farnborough, UK; Healthcare Safety Investigation Branch; December 18, 2019.
    Maternal care during and after childbirth is at risk for never events including retained foreign objects. This analysis of a sentinel event involving a retained surgical tampon after childbirth discusses communication, fatigue, and process factors that contributed to the incident. The report suggests improved handoffs as one improvement strategy.
    Nurse staffing levels, missed vital signs and mortality in hospitals: retrospective longitudinal observational study.
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    • Griffiths P, Ball JE, Bloor K, et al. National Institute for Health Research; 2018.
    Missed nursing care has been linked to safety problems, but ensuring reliable levels of nurse staffing remains challenging. This report provides the results of a 3-year investigation into whether tracking of vital signs by nursing staff could serve as a viable measure for safe patient coverage. The report identified correlations between low staffing, missed vital sign observation, length of stay, and likelihood of mortality. However, record review found no direct relationship between safety and staffing levels. A PSNet perspective examined the relationship between missed nursing care and patient safety.
    Silence Kills: The Seven Crucial Conversations for Healthcare.
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    • Maxfield D, Grenny J, McMillan R, Patterson K, Switzler A. Provo, UT: VitalSmarts, L.C; 2005. 

    The American Association of Critical-Care Nurses (AACN) commissioned VitalSmarts to conduct a study exploring communication difficulties experienced by health care personnel that may contribute to medical error. Areas of concern include broken rules, mistakes, lack of support, incompetence, poor teamwork, disrespect, and micromanagement.
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