All Content

 Cancer test communication failures can contribute to physical, emotional, and financial patient harm. This report examines missed opportunities made by multiple clinicians involved in the care of a patient with prostate cancer who then died from metastasized disease Seven recommendations are included for improving abnormal test result communication and error management at the facility.

This site provides promotional materials for an annual awareness campaign on patient safety that takes place in the autumn. The 2021 observance, focusing on the importance of essential care partners, was held October 25th through 29th.

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. 

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.

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.   

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.

This bill submits amendments to existing US federal law to strengthen state-organized efforts to improve health care-associated infection control efforts, pediatric safety initiatives, care transitions, reporting systems and antimicrobial stewardship programs.

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

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.

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.

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.

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.

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.

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.

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.

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.

This certificate program for laboratory professionals offers six courses aimed at enhancing participants' skills in establishing a just culture, identifying safety hazards, and assessing gaps in processes to reduce risks of specimen management errors.

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.