The PSNet Collection

Multiple Failures in Test Results Follow-up for a Patient Diagnosed with Prostate Cancer at the Hampton VA Medical Center in Virginia.

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Washington, DC: VA Office of the Inspector General; June 28, 2022. Report No 21-03349-186.

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.

Curated Libraries

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.

Deficiencies in Inpatient Mental Health Care Coordination and Processes Prior to a Patient's Death by Suicide, Harry S. Truman Memorial Veterans' Hospital in Columbia, Missouri.

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Washington, DC: Department of Veterans Affairs, Office of Inspector General. January 5, 2021. Report No. 20-01521-48.

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.

The Life and Death of Elizabeth Dixon: A Catalyst for Change.

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Kirkup B. London, England: Crown Copyright; 2020. ISBN 9781528622714.

Missed diagnosis of a dangerous condition in utero, treatment errors, lack of response to concerns raised, and inadequate clinician expertise were among the contributing factors identified in this analysis of the death of a special needs infant at home. The 12 recommendations stemming from the investigation include improvements in disclosure support, clinician communication across facilities, and assignment of accountability when false and misleading statements are made during investigations.

The Economics of Patient Safety Part III: Long-term Care: Valuing Safety for the Long Haul.

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de Bienassis K, Llena-Nozal A, Klazinga N for the Organisation for Economic Co-operation and Development. Paris, France: OECD Publishing; 2020. OECD Health Working Papers, No. 121.

Adverse events in long term care facilities are acerbated due to staffing, training and financial challenges. This report examined the costs of avoidable problems in long term care and suggests prevention strategies that center on workforce skill development and safety culture improvement.

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.

Maryland Hospital Patient Safety Program Annual Report.

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Office of Health Care Quality. Baltimore, MD: Maryland Department of Health and Mental Hygiene.

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.

Potentially Preventable Readmissions: Conceptual Framework To Rethink the Role of Primary Care. Executive Summary.

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Maxwell J, Bourgoin A, Crandall J. Rockville, MD : Agency for Healthcare Research and Quality; 2020.

Project RED re-engineered discharge with the goal of reducing preventable readmissions. This report summarizes an Agency for Healthcare Research and Quality project to transfer the Project RED experience to the primary care environment. Areas of focus included enhancing the team leader role of primary care physicians in post-discharge care.

Drug Shortages: Root Causes and Potential Solutions.

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Drug Shortage Task Force. Silver Spring, MD: US Food and Drug Administration; 2020.

Drug shortages result from a variety of systemic failures. This report identifies market demands and financial factors that disrupt medication production. The materials recommend development of shared mental models on the causes of medication shortages and how they affect patients. Legislative and pharmaceutical industry-level quality improvement strategies designed to address systemic weaknesses are reviewed.

Overview of the Environmental Scan of Primary Care-Based Effort To Reduce Readmissions.

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Hochman M, Bourgoin A, Saluja S, et al. Rockville, MD: Agency for Healthcare Research and Quality; March 2019. AHRQ Publication No. 18(19)-0055-EF.

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.

Ignoring the Alarms: How NHS Eating Disorder Services Are Failing Patients.

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London, UK: Parliamentary and Health Service Ombudsman; 2017. ISBN: 9781528601344.

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.

Toolkit to Engage High-Risk Patients in Safe Transitions Across Ambulatory Settings.

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Davis K, Collier S, Situ J, et al. Rockville, MD: Agency for Healthcare Research and Quality; December 2017. AHRQ Publication No. 1800051EF.

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.

Designing and Delivering Whole-Person Transitional Care: Hospital Guide to Reducing Medicaid Readmissions.

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Boutwell A, Bourgoin A , Maxwell J, et al. Rockville, MD: Agency for Healthcare Research and Quality; September 2016. AHRQ Publication No. 16-0047-EF.

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 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.

Actions Needed to Improve Newly Enrolled Veterans' Access to Primary Care.

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Washington, DC: United States Government Accountability Office; March 18, 2016. Publication GAO-16-328.

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.

Actions Needed to Help Ensure Appropriate Medication Continuation and Prescribing Practices.

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Washington, DC: United States Government Accountability Office; January 5, 2016. Publication GAO-16-158.

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.

Freedom to Speak Up: A Review of Whistleblowing in the NHS.

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Francis R. London, UK: Department of Health; February 2015.

Staff willingness to raise awareness of problems that could affect patient care is an important indicator of safety culture. This publication explores National Health Service (NHS) staff perceptions regarding raising concerns about health care safety. Barriers to speaking up were related to organizational culture, incident management, and legal protection for whistleblowers. The report also suggests measures for NHS organizations to use to help ensure that staff are comfortable raising awareness of patient safety concerns.

Healthcare Inspection: Evaluation of the Veterans Health Administration's National Consult Delay Review and Associated Fact Sheet.

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Daigh JD Jr. Washington, DC: VA Office of the Inspector General; December 15, 2014. Report No. 14-04705-62.

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.

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