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Farnborough, UK: Healthcare Safety Investigation Branch; February 17, 2022.

Pre-hospital emergency care can be vulnerable to timing, information, and task failures that compromise safety. This investigation explores how computerized decision support system access played a roles in an emergency call-center program incident where erroneous information was transmitted to a pregnant patient that contributed to infant harm.

Washington, DC: Veterans Affairs Office of Inspector General; August 26, 2021. Report No. 21-01502-240.

Organizational assessments often provide insights that address overarching quality and safety challenges. This extensive inspection report shares findings from inspections of 36 Veterans Health Administration care facilities. Recommendations drawn from the analysis call for improvements in suicide death review, root cause analysis result application, and safety committee action item implementation.
Brody JE. New York Times. 2020.
Inappropriate care activities can cascade to significantly impact patient safety. This article shares how medication side effects can be misdiagnosed to perpetuate harm in older patients rather than getting to the root of the care concerns. 

SB 3380. 116th Congress (2020).

This bill submits amendments to existing US federal law to strengthen state-organized efforts to improve health care-associated infection control efforts, pediatric safety initiatives, care transitions, reporting systems and antimicrobial stewardship programs.
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.
New Jersey Hospital Association, the Ohio Hospital Association and The Hospital and Healthsystem Association of Pennsylvania. Q3 Health Innovation Partners.
Local efforts that draw from the experience of its leaders serve an important role in generating patient safety improvement. This collaboration merges the efforts of three organizations as participants in the federal Partnerships for Patients initiative to engage their constituents in regionally focused safety and quality improvement.