This magazine article reports on the preventable death of a patient during an acute asthma attack. Written by the patient's husband, the article outlines the failures that led to her death despite the fact that she was at the door of a hospital emergency department and on the phone with an emergency dispatcher. Factors discussed include overreliance on poorly functioning technology, communication failures, and lack of fail-safes.

Maternal death is a sentinel event. This news article reports on two incidents at one hospital that prompted investigations and describes strategies to improve maternal safety, including standardizing procedures and enhancing communication.

Patients who experience harm while receiving medical care can serve as powerful advocates for patient safety. This news article reports on a patient who became engaged in working to redesign processes to improve patient safety after he became paralyzed from the chest down due to a cascade of communication errors.

Information exchange can be challenging when nurses hand off care responsibilities at the end of their shifts. This news article discusses bedside shift reports as a strategy to improve communication among nursing staff and engage patients in their care.

This online resource provides instructions and templates for implementing team-based, collaborative care. This group's collaborative care model has received a John M. Eisenberg Award for contributions to patient safety.

Clinician communication with patients and families during transitions has been a focus of safety improvement efforts. This newspaper article describes insights from a resident physician regarding how poor communication between teams caring for patients can result in unnecessary care, family discomfort, and confusion for the patient receiving different information among varying teams.

Reporting on weaknesses in laboratory testing methods, this news article discusses patients' experiences with testing errors to illustrate how such failures can contribute to patient harm—such as missed or delayed diagnosis—and raises concerns about insufficient transparency, investigations, and regulations around laboratory facilities with poor processes.

Reporting on a case involving an overlooked test result that contributed to the death of a patient in the military medical system, this newspaper article highlights how insufficient transparency can prevent patients and their families from learning about what happened during their care and hinder opportunities to recognize processes in need of improvement.

This newspaper article describes how surgical complications, health care–associated infections, and ineffective patient–provider communication contributed to a patient's experience with harm and suggests that transparency around the incident and preoperative patient briefings could have improved the situation.

Reporting on serious lapses in the care provided by the military health system, this newspaper article highlights how systemic problems, such as inadequate review of incidents, poor communication, and lack of transparency, can contribute to patient harm.

Studies have shown that a surprisingly large proportion of hospitalized patients are not aware of their diagnoses or treatment plan and that their preferences are often not taken into account in advanced care planning. This failure to provide patient-centered care indicates a need for increased patient engagement in safety and quality efforts. This toolkit published by the Agency for Healthcare Research and Quality is designed to help hospitals develop partnerships with patients around improving safety. Developed with input from clinicians and patients, the guide emphasizes four strategies—working with patients as advisors, improving bedside communication, integrating patients and families into shift changes, and using patient input to improve the discharge process. An AHRQ WebM&M perspective by Dr. Saul Weingart discusses the practical challenges of engaging patients in improvement efforts.

This Web site provides resources for clinicians and patients to help achieve safe care transitions.

This Web site provides access to materials for patient safety improvement efforts in Minnesota, including initiatives to reduce adverse drug events and hospital collaboratives to implement best practices.

This video reveals how checklists can help patients and their families ensure safety during hospital care.