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After a failed induction at 36 weeks, a 26-year-old woman underwent cesarean delivery which was complicated by significant postpartum hemorrhage. The next day, the patient complained of severe perineal and abdominal pain, which the obstetric team attributed to prolonged pushing during labor. The team was primarily concerned about hypotension, which was thought to be due to hypovolemia from peri-operative blood loss. After several hours, the patient was transferred to the medical intensive care unit (ICU) with persistent hypotension and severe abdominal and perineal pain. She underwent surge

This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.

J Health Serv Res Policy. 2015;20(suppl 1):S1-S60.

Articles in this special supplement explore research commissioned by National Institute for Health Research in the United Kingdom to address four patient safety research gaps: how organizational culture and context influence evaluations of interventions, organizational boundaries that affect handovers and other aspects of care, the role of the patient in safety improvement, and the economic costs and benefits of safety interventions.
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.
Due to a series of incomplete signouts, information about a patient's post-operative leg pain and chest discomfort is not conveyed to the primary team. A PE is discovered post-mortem.
Trusting an incorrectly labeled chest x-ray over physical exam findings, a resident places a chest tube for pneumothorax in the wrong side.