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Harm Caused by Delays in Transferring Patients to the Right Place of Care.

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Farnborough, UK: Healthcare Safety Investigation Branch; June 2022.

Handoffs between prehospital emergency medical services (EMS) providers and hospital emergency departments (EDs) can be suboptimal, which increases patient harm potential. This interim report examines National Health Service discharge delays. It suggests a systemic approach is needed to address flow and capacity factors that contribute to ineffective and unsafe interfacility discharge and transfer.

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Maternal Safety

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.

Unwell Women: Misdiagnosis and Myth in a Man-Made World.

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Cleghorn E. New York, NY: Dutton; 2021. ISBN: 9780593182956.

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.

Deficiencies in Care, Care Coordination, and Facility Response to a Patient Who Died by Suicide, Memphis VA Medical Center in Tennessee.

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Washington, DC: Department of Veterans Affairs, Office of Inspector General; September 3, 2020. Report No 19-09493-249.

Discontinuities in mental health care are a patient safety concern. This report analyzes how documentation gaps, medication reconciliation problems, and poor care coordination contributed to the suicide of a patient who presented at an emergency room, was screened there, and referred to a clinic for further care that was not completed.

Inadequate Emergency Department Care and Physician Misconduct at the Washington DC VA Medical Center.

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Office of the Inspector General. Washington, DC: Department of Veterans Affairs; July 28, 2020. Report Number 19-07507-214.

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.

The Diagnosis of Ectopic Pregnancy.

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Farnborough, UK: Healthcare Safety Investigation Branch; March 2020.

Missed or delayed diagnosis in maternal care can result in serious harm to both the mother and the child. This report analyzes a delayed diagnosis ectopic pregnancy incident and found that referral and discharge missteps contributed to the error.

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.

Error Reduction and Prevention in Surgical Pathology, Second Edition.

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Nakhleh RE, Volmar KE, eds. Cham, Switzerland: Springer Nature; 2019. ISBN: 9783030184636.

Surgical specimen and laboratory process problems can affect diagnosis. This publication examines factors that contribute to errors across the surgical pathology process and reviews strategies to reduce their impact on care. Chapters discuss areas of focus to encourage process improvement and error response, such as information technology, specimen tracking, root cause analysis, and disclosure.

Patient and Family Engagement in Primary Care: Case Studies.

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Rockville, MD: Agency for Healthcare Research and Quality; September 2016. AHRQ Publication No. 16-0035-2-EF.

Patient safety in ambulatory care is receiving increased attention. This guide includes case studies that explore how Open Notes, team-based care delivery, and patient and family advisory committees have shown promise as patient engagement and safety improvement mechanisms in primary care settings.

Implications of Health Literacy for Public Health: Workshop Summary.

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Hewitt M, Hernandez LM; Roundtable on Health Literacy, Board on Population Health and Public Health Practice, Institute of Medicine. Washington, DC: National Academies Press; 2014. ISBN: 9780309303651.

Health literacy can affect patients' ability to understand directions, ask good questions, and participate in care. Framing health literacy as a public health challenge, this report describes efforts to address it in three states and explores implementation and research to improve it across the United States.

FDASIA Health IT Report: Proposed Strategy and Recommendations for a Risk-Based Framework.

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Washington, DC: Office of the National Coordinator for Health Information Technology, Federal Communications Commission. Silver Spring, MD: Food and Drug Administration. April 2014.

While implementation of health information technology (IT) is widely recommended, research has raised the concern that it may lead to unintended consequences on patient safety. This draft report explores key recommendations for ensuring the safe use of health IT, such as the establishment of a "Health IT Safety Center" to test, disseminate, and promote assessment tools. The comment submission period is now closed.

Findings and Lessons From the Improving Management of Individuals With Complex Health Care Needs Through Health IT Grant Initiative.

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Rockville, MD: Agency for Healthcare Research and Quality; September 2013. AHRQ Publication No. 13-0058-EF.

This publication summarizes findings from 12 projects that explored how health information technology can enhance management and quality of care for patients with complex conditions in the ambulatory setting.

Clinical ICT Systems in the Victorian Public Health Sector.

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Doyle J. Melbourne, Australia: Victorian Auditor-General's Office; October 30, 2013.

Following the implementation of a large clinical information communication technology project, this report identified interoperability and usability failures and noted medication ordering and management as particularly vulnerable to errors.

Order from Chaos: Accelerating Care Integration.

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Boston, MA: Lucian Leape Institute at the National Patient Safety Foundation; October 2012.

This report discusses the need for improved coordination and integration in patient care to reduce preventable errors.

The Rebecca O'Malley Report.

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Cork, Ireland: Health Information and Quality Authority; March 21, 2008.

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

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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