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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.
Office of Health Care Quality. Baltimore, MD: Maryland Department of Health and Mental Hygiene.
This annual report summarizes never events in Maryland hospitals over the previous year. From July 2019-June 2020, reported pressure ulcers increased while treatment delays and surgery-related events decreased. The authors recommend several corrective actions to build on training and policy changes to guide improvement work, including improving team communication and use of hospital data to reduce delays.
Hochman M, Bourgoin A, Saluja S, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2019. AHRQ Publication No. 18(19)-0055-EF.
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.
Davis K, Collier S, Situ J, et al. Rockville, MD: Agency for Healthcare Research and Quality; December 2017. AHRQ Publication No. 1800051EF.
Transitions are known to be vulnerable to communication errors. This toolkit focuses on patient transitions between ambulatory care environments and encourages staff to engage patients and families in their care to prevent errors during care transitions.
Washington, DC: United States Government Accountability Office; March 18, 2016. Publication GAO-16-328.
This analysis found that scheduling problems among patients seeking primary care from Veterans Affairs health systems continue to occur. The report outlines weaknesses in the data collected to measure and evaluate veterans' access to primary care and spotlights the need to develop and disseminate a comprehensive policy for Veterans Affairs schedulers to reduce risk of scheduling errors.
Washington, DC: United States Government Accountability Office; January 5, 2016. Publication GAO-16-158.
The Veterans Health Administration faces various challenges to providing safe care, including poor continuity during transitions to different locations which can result in inappropriate discontinuation of medications that patients require. This government report discuses efforts to reduce gaps in medication access and suggests developing clear policies to prevent patient harm in this population.
Francis R. London, UK: Department of Health; February 2015.
Staff willingness to raise awareness of problems that could affect patient care is an important indicator of safety culture. This publication explores National Health Service (NHS) staff perceptions regarding raising concerns about health care safety. Barriers to speaking up were related to organizational culture, incident management, and legal protection for whistleblowers. The report also suggests measures for NHS organizations to use to help ensure that staff are comfortable raising awareness of patient safety concerns.
Daigh JD Jr. Washington, DC: VA Office of the Inspector General; December 15, 2014. Report No. 14-04705-62.
Misrepresentation of findings, either by accident or design, can result in ineffective use of resources and poor decision-making. This investigation found inconsistencies in the information reported by the Veterans Health Administration in the widely-publicized analysis discussing weaknesses in the organization that resulted in delayed care. The author calls for the assessment to be revisited to ensure conclusions and work toward improvement are verifiable to augment the safety and timeliness of care provided to veterans.
Boonyasai RT, Ijagbemi OM, Pham JC, et al. Rockville, MD: Agency for Healthcare Research and Quality; December 2014. AHRQ Publication No. 14(15)-0067-EF.
This report analyzes the literature discussing emergency department discharge processes and highlights elements of high-quality discharges and risk factors for suboptimal discharges. The in-depth review summarizes interventions currently implemented to augment discharge procedures, care coordination, and the identification of patients more susceptible to poor discharge.
Hearing Before the Committee on Veterans' Affairs United States Senate. 113th Cong (September 9, 2014).
In this hearing Veterans Affairs leadership provide an update on the current investigation into data and scheduling manipulation in the VA system. The testimonies discuss the scope of the problem, suggest that the culture at the hospitals enabled record falsification to become normalized, and outline actions being taken to address weaknesses in processes and access to care.
Agency for Healthcare Research and Quality; AHRQ.
This article describes an intervention that trained health coaches to use mobile technology to assess the health status of recently discharged Medicare patients, first during an in-home visit 48 hours after leaving the hospital and then with weekly phone calls over a 3-week period. The program resulted in decreased readmission rates and significant cost savings.
Sixth Report of Session 2008–09. House of Commons Health Committee. London, England: The Stationery Office; July 3, 2009. Publication HC 151-I.
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.
Schoen C, Osborn R, Huynh PT, et al. Health Aff (Millwood). 2005;24;Suppl1.
This Commonwealth Fund-sponsored survey provides an international perspective from patients from Australia, Canada, Germany, New Zealand, the United Kingdom, and the United States. Overall, the findings collectively suggest that no single country stands alone as the best or worst in the identified health care issues. These issues included transitional care and care coordination, medication safety, chronic care management and patient-centered care, and timely access. The United States, for instance, seemed to suffer from fragmentation of care and inadequate insurance as well as limitations in access and efficiency. However, each country shared certain strengths and challenges. The findings suggest that fundamental changes to health care will be necessary, beyond current efforts targeting payment and delivery systems.