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Broken, fragmented health-care system failed daughter who died by suicide.

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Klowak M. CBC News. March 9, 2020.

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.

Improving Communication During Transitions of Care.

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Oakbrook Terrace, IL: Joint Commission Resources; 2010. ISBN: 9781599404097.

This guide discusses the impact of poor communication on care transitions and describes tactics for improvement.

Applying Toyota Production System principles to a psychiatric hospital: making transfers safer and more timely.

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Young JQ, Wachter RM. Jt Comm J Qual Patient Saf. 2009;35:439-448.

This study describes the application of Toyota Production System principles, which emphasize designing standardized and reliable work processes by an iterative process of testing and evaluation, to improving patient safety and continuity of care at a psychiatric institution.

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