Care transitions present opportunities for errors. This issue brief highlights the risk of diagnostic errors during transitions in care, such as from the emergency department to the inpatient floor or from inpatient to outpatient care. The brief describes strategies to prevent and reduce these errors, such as diagnostic feedback or structured handoff tools.

Women have been affected by implicit bias that undermines the safety of their care and trust in the medical system. This book shares the history anchoring the mindsets driving ineffective care for women and a discussion of the author’s long-term lupus misdiagnosis.

This investigation examined care coordination, screening and other factors that contributed to a patient death by suicide shortly after discharge from a Veteran’s Hospital. Event reporting, disclosure and evaluation gaps were identified as process weaknesses to be addressed. 

Patient suicide is a never event. This report analyzes the death of a veteran after presenting at an emergency room with suicidal ideation. The analysis found lack of both suicide prevention policy adherence and appropriate assessment, as well as a lack concern for the patient’s condition contributed to the failure.   

Reducing adverse medication events is a worldwide challenge. This collection of technical reports explores key areas of concern that require action at a system level to improve: high-alert medications, polypharmacy, and medication use at care transitions. Each monograph provides an overview of the topic as well as practical improvement approaches for patients, clinicians, and organizations.

Patient stories offer important insights regarding the impact medical errors have on patients and their families. This book shares the author's experience with medical error and spotlights how lack of transparency in European health care can contribute to avoidable process failures that result in patient harm.

Patients with mental health conditions face particular safety challenges. This report describes incidents involving patients with eating disorders who experienced harm while receiving care in National Health Service organizations. Factors that contributed to the failures included poor care coordination, premature discharge, and lack of monitoring. The report discusses gaps in the investigations of these patient deaths and outlines areas of improvement.

This toolkit provides information for hospitals to help reduce preventable readmissions among Medicaid patients. Building on hospital experience with utilizing the materials since 2014, this updated guide explains how to determine root causes for readmissions, evaluate existing interventions, develop a set of improvement strategies, and optimize care transition processes.

A previous report by the Veterans Affairs (VA) Office of the Inspector General found that many veterans at the Phoenix VA facility endured months-long waits for primary care appointments, due in part to inappropriate manipulation of the scheduling process so that the facility could appear to meet VA quality metrics. This follow-up report examined whether these delays led to patients experiencing preventable harm and further investigated the root causes of excessive wait times and the generalizability of the problem across the VA system. The investigators concluded that no deaths or serious harm could be directly attributed to the scheduling delays; however, the report uncovered many examples of poor quality care, including delayed diagnoses of cancer, preventable readmissions, and poor care coordination. It also appears that scheduling manipulation was rife throughout the system. The report strongly attributes the "corrosive culture" of the VA and its unresponsive leadership as major factors in the system's failure to address longstanding problems with access to care. Though the VA has achieved impressive accomplishments in providing high-quality care, the scheduling scandal has caused serious damage to its reputation. A recent commentary by Dr. Kenneth Kizer (who, as Undersecretary for Health in the VA, was widely credited for reforming the VA in the 1990s) and Dr. Ashish Jha recommends several reforms the VA should implement to transform its culture and restore its standards.

This investigation outlines how inadequate care contributed to the death of a child who developed sepsis while receiving treatment for the flu. Describing failures associated with telephone triage and out-of-hours service in the course of his care, the report recommends organization-wide efforts to improve safety, including providing guidelines for staff and support or families.

This report analyzes the findings of a diagnostic error investigation and provides numerous recommendations to improve standards for treating symptomatic breast disease.

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.

Personal stories illustrate the systems issues that contribute to mismanagement of patients as they move from provider to provider throughout the health care system.

This report examines the emerging field of health literacy by discussing promotional strategies to raise awareness and by identifying key organizations to foster research, guide policy development, and drive improvement efforts.