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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.

Ellis B, Hicken M. CNN. May 14, 2020.

Long-term care and skilled nursing facilities care for a patient population particularly vulnerable to COVID-19 infection. This article discusses an analysis of a large nursing home system and gaps in its workforce safety program. Problems highlighted included communication practices that fall short of what is needed to assure staff safety as they care for nursing home residents.
Arditi L. Peoples Public Radio. December 3, 2019.
Emergency medical services are often provided under chaotic circumstances that may contribute to failure. This story highlights a series of esophageal intubation errors and efforts to minimize this “never event” across the state of Rhode Island. Improvement strategies discussed include practice restrictions for EMT personnel and use of less invasive, less risky processes to provide oxygen as an alternative to intubation, which may reduce esophageal intubation errors