The PSNet Collection

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

Save to Library

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.

Curated Libraries

Maternal Safety

Unlocking Solutions in Imaging: Working Together to Learn from Failings in the NHS.

Save to Library

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.

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

Save to Library

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.

Save to Library

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.

The Diagnosis of Ectopic Pregnancy.

Save to Library

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.

Save to Library

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.

Deny, Dismiss, Dehumanise: What Happened When I Went to Hospital.

Save to Library

Cullen A. Uitgeverij van Brug: The Hague, The Netherlands; 2019. ISBN: 9789065232236.

Patient stories offer important insights regarding the impact medical errors have on patients and their families. This book shares the author's experience with medical error and spotlights how lack of transparency in European health care can contribute to avoidable process failures that result in patient harm.

Nurse staffing levels, missed vital signs and mortality in hospitals: retrospective longitudinal observational study.

Save to Library

Griffiths P, Ball JE, Bloor K, et al. National Institute for Health Research; 2018.

Missed nursing care has been linked to safety problems, but ensuring reliable levels of nurse staffing remains challenging. This report provides the results of a 3-year investigation into whether tracking of vital signs by nursing staff could serve as a viable measure for safe patient coverage. The report identified correlations between low staffing, missed vital sign observation, length of stay, and likelihood of mortality. However, record review found no direct relationship between safety and staffing levels. A PSNet perspective examined the relationship between missed nursing care and patient safety.

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

Save to Library

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.

Safely Home: What Happens When People Leave Hospital Care Settings?

Save to Library

London, UK: Healthwatch England; July 2015.

Discharges are vulnerable periods for patients, often due to miscommunication, delays, and lack of patient-centeredness. This report reviews experiences of more than 3000 patients in England regarding the effects of poor discharge. The results, which focus on older and homeless patients (given the increased potential for negative clinical consequences in these populations), highlights several practices that can improve the safety of hospital discharges.

Patient Safety in Ambulance Services: A Scoping Review.

Save to Library

Fisher JD, Freeman K, Clarke A, et al. Southampton, UK: NIHR Journals Library; May 2015.

The safety of emergency medical care delivered in conjunction with ambulance services has not been studied in the United Kingdom. Analyzing evidence associated with ambulance care, this scoping review found that inconsistent use of terminology was a problem and identified specific areas that require further research to develop safer models of prehospital care, including diagnosis and treatment, equipment use, and ambulance-to-hospital handover.

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

Save to Library

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.

An Avoidable Death of a Three-year-old Child from Sepsis.

Save to Library

London, UK: Parliamentary and Health Service Ombudsman; June 2014.

This investigation outlines how inadequate care contributed to the death of a child who developed sepsis while receiving treatment for the flu. Describing failures associated with telephone triage and out-of-hours service in the course of his care, the report recommends organization-wide efforts to improve safety, including providing guidelines for staff and support or families.

Managing Patients' Medicines after Discharge from Hospital.

Save to Library

London, UK: Care Quality Commission; October 2009. CQC-039-500-ESP-102009. ISBN: 9781845622442.

This report analyzed how medication information is shared among UK practices and patients after a hospital stay and found that 81% of general practices thought that patient information given to them from hospitals was incomplete or inaccurate.

Practical Patient Safety.

Save to Library

Reynard J, Reynolds J, Stevenson P. Oxford, UK: Oxford University Press; 2009. ISBN: 9780199239931.

This book provides an introduction to key patient safety topics and includes a set of 20 case studies to demonstrate opportunities for error prevention.

Patient Safety and Adverse Events.

Save to Library

Adlassnig KP, Blobel B, Mantas J, Masic I, eds. Stud Health Technol Inform. 2009;150:497-566. In: Medical Informatics in a United and Healthy Europe. Washington, DC: IOS Press. ISBN: 9781607500445.

Part of a comprehensive electronic compilation on medical informatics, this series of papers examines topics surrounding the use of health information technology (HIT) to detect, report, and learn from adverse events.

Patient Safety.

Save to Library

Sixth Report of Session 2008–09. House of Commons Health Committee. London, England: The Stationery Office; July 3, 2009. Publication HC 151-I.

This government report analyzes the National Health Service's efforts to enhance patient safety and recommends improving certain areas, such as adopting technology, analyzing failure, and ensuring both practitioner education and adequate staffing.

State of Healthcare 2008.

Save to Library

The Healthcare Commission. London, UK: The Stationary Office; 2008.

This report shares findings from a 5-year analysis of the state of health care in the United Kingdom. It reveals that while awareness of patient safety has improved since the first report in the series, the UK health system needs to be more consistent in its application of patient-centeredness concepts to fully promote quality.

The Rebecca O'Malley Report.

Save to Library

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.

All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

All Content

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Case

Continue as a Guest

Continue Logged In

Submit Your Case

Continue as a Guest

Already have a PSNet

Account?

New Users