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Mirarchi FL, Cammarata C, Zerkle SW, et al. J Patient Saf. 2015;11(1):9-17.
This survey of emergency department physicians found that significant confusion in understanding of Physician Orders for Life-Sustaining Treatment (POLST) documents exists. The authors suggest that additional research and training are required to protect patients' decisions. A related study revealed variation in interpretations of POLST orders by prehospital emergency responders. A previous AHRQ WebM&M commentary discusses how confusion in resuscitation status can result in a patient receiving unwanted care.
Dawson S, King L, Grantham H. Emergency Medicine Australasia. 2015;25.
Handoffs between care settings can lead to adverse events. This literature review analyzed 17 studies of handoffs between prehospital first responders and emergency department (ED) staff. Safety gaps detected included communication barriers, lack of a structured communication tool, and unclear identification of the receiving clinical staff. The authors suggest that a structured handoff tool could improve first responder–ED handoffs. A past AHRQ WebM&M commentary discussed communication failures between providers and highlighted a need for standard handoff protocols.
Irving, TX: American College of Emergency Physicians; 2014.
This guidance recognizes risks associated with emergency medical services and provides recommendations to support the implementation of a safety culture in this setting.

Brice JH, Patterson PD, eds. Prehosp Emerg Care. 2012;16:1-108.  

This special issue contains articles exploring safety improvement efforts in emergency medical services.
Gustafsson M, Wennerholm S, Fridlund B. Intensive Crit Care Nurs. 2010;26:138-45.
Few studies have addressed patient safety issues during inter-hospital patient transport. This Swedish study used critical incident debriefing techniques to explore factors leading to potential safety problems during transport, based on the perceptions of experienced transport nurses.
After an hour of failed resuscitative efforts, a woman who collapsed in a market is pronounced dead in the emergency department (ED). Only later do the paramedics and physician discover a small bullet in the patient's chest.
Interrupted during a telephone handoff, an ED physician, despite limited information, must treat a patient in respiratory arrest. The patient is stabilized and transferred to the ICU with a presumed diagnosis of aspiration pneumonia and septic shock. Later, ICU physicians obtain further history that leads to the correct diagnosis: pulmonary embolism.
An elderly man, recently discharged from one hospital after having his automated internal cardioverter-defibrillator (AICD) replaced, is taken to another hospital when his AICD misfires multiple times.
Lankshear A, Lowson K, Harden J, et al. J Adv Nurs. 2008;63.
This study demonstrated that simply designing "system" safeguards fails to prevent errors in subsequent monitoring and implementation. Investigators used three safety alerts, including latex allergy, as markers of how well these alerts were being adopted in practice by bedside nurses.
Gillman L, Leslie G, Williams T, et al. Emerg Med J. 2006;23:858-61.
This study evaluated nearly 300 adverse events that occurred during intrahospital transport, noting that equipment problems and hypothermia were the most common. Investigators combined 6 months of prospective observation with retrospective chart review to characterize the type and nature of events recorded for patients admitted to the intensive care unit from the emergency department. While the overall rates were lower than reported in past research, the authors advocate for using their findings as benchmarks: an adverse event rate of 22 of 100 transfers and 38 of 100 delays in transfer. A case commentary on Agency for Healthcare Research and Quality (AHRQ) WebM&M discusses the issue of intrahospital transport with suggestions for improving the safety of this poorly studied process.