The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.
System weaknesses are often at the root of never events. This news story discusses the suicide of a concussed woman whose care failed due to gaps in team communication, discharge and transition practices.
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