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.
Karlamangla S. Los Angeles Times. December 1, 2019.
Patient suicide is considered a sentinel event. This feature shares an examination of approximately 100 preventable deaths in the State of California over a decade. An examination of the case records identified breakdowns in care processes such as lack of training, low staffing and human error.
Psychiatric patients are vulnerable to particular safety hazards. This news article reports on unintended consequences associated with a strategy to help patients adapt to being discharged home by providing passes for them to adjust to independent living.
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