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Lockhart B, Mascie-Taylor H. Crown Copyright: London, England; June 2022. ISBN 9781912313631.

Misdiagnosis of neurological conditions, such as stroke, can lead to delays in treatment and patient morbidity and mortality. This report outlines findings from an inquiry into one misdiagnosis attributed to one neurologist in Ireland and discusses the leadership, system, process, and communication failures which permitted misdiagnoses to go unchecked.

Under the Skin. The Hidden Toll of Racism on American Lives and on the Health of our Nation.

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Villarosa L. New York, NT: Doubleday: 2022. ISBN 9780385544887.

Health inequities are receiving increased attention as a patient safety issue. This book examines the persistent problem of systemic racism on the health of Black patients. It summarizes the evidence on how racism affects health care and discusses strategies for improvement such as reducing gaps in implicit bias content in curriculum.

Harm Caused by Delays in Transferring Patients to the Right Place of Care.

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Farnborough, UK: Healthcare Safety Investigation Branch; June 2022.

Handoffs between prehospital emergency medical services (EMS) providers and hospital emergency departments (EDs) can be suboptimal, which increases patient harm potential. This interim report examines National Health Service discharge delays. It suggests a systemic approach is needed to address flow and capacity factors that contribute to ineffective and unsafe interfacility discharge and transfer.

Final Report of the Ockenden Review.

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London UK: Crown Copyright; March 30, 2022. ISBN: 9781528632294.

Maternal and baby harm in healthcare is a sentinel event manifested by systemic failure. This report serves as the final conclusions of an investigation into 250 cases at a National Health System (NHS) trust. The authors share overarching system improvement suggestions and high-priority recommendations to initiate NHS maternity care improvement.

Maternity Pre-arrival Instructions by 999 Call Handlers.

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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.

Achieving Excellence in Cancer Diagnosis: Proceedings of a Workshop—in Brief.

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National Academies of Sciences, Engineering, and Medicine. Washington, DC: The National Academies Press; 2022.

Diagnostic errors remain an ongoing challenge in many medical specialties, including oncology. This workshop reviewed the evidence base examining challenges in cancer diagnosis, discussed suggestions for improvement in the field, and looked toward a safer future for cancer patients.

Community Living Centers: VA Needs to Strengthen Its Approach for Addressing Resident Complaints.

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Washington, DC: United States Government Accountability Office; November 30, 2021. Publication GAO-22-105142.

Patient complaints have the potential to be used for care improvement as they surface problems in health facilities. This report examined complaint response processes in Veterans Affairs nursing homes and found them lacking. Five recommendations submitted to drive improvement underscore the value of adherence to policy and the transfer of complaint experiences to leadership.

Confronting Racism in Health Care: Moving from Proclamations to New Practices.

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Hostetter M, Klein S. New York, NY: Commonwealth Fund; October 18, 2021

Structural racism affects the safety and equity of care delivery. This report summarizes organizational efforts to reduce the impact of systemic racism on patient care, hiring practices, and policy implementation to ensure transparent, equitable and patient-centered care is reliably available to all.

Evaluation of Quality, Safety, and Value in Veterans Health Administration Facilities, FY 2020.

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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.

The Safety of Maternity Services in England.

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Fourth Report of Session 2021–22. House of Commons Health Committee. London, England: The Stationery Office; July 6, 2021. Publication HC 19.

High-profile failures motivate examination and change of existing services. This report builds on maternity care failures in National Health Service trusts to recommend needed changes in learning from failure to effectively support clinicians providing maternity care, provide patient-centered care to mothers and babies, and learn from untoward incidents to enhance care safety.

Do black and white patients experience similar rates of adverse safety events at the same hospital?

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Gangopadhyaya A. Washington DC; Urban Institute: July 2021.

Racial inequities have been revealed by the COVID pandemic as a distinct patient safety concern. This report examined racial differences using patient safety indicators to measure hospital-acquired conditions, insurance coverage, and hospital patient population. The results indicate Black patients have reduced safety, that insurance coverage had little influence on safety and hospitals with a higher Black patient population experienced more adverse events that those serving a white patient population.

Deficiencies in Emergency Preparedness for Veterans Health Administration Telemental Health Care at VA Clinic Locations Prior to the Pandemic.

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Washington, DC: Department of Veterans Affairs, Office of Inspector General. June 24, 2021. Report No. 19-09808-171.

This report examined veterans' health clinic use of telemental health to identify safety challenges inherent in this approach before the expansion of telemedine during the COVID-19 crisis. The authors note the complexities in managing emergent mental health situations in virtual consultations. Recommendations for improvement included emergency preparedness planning, specific reporting of telemental health incidents and organized access to experts.

Unwell Women: Misdiagnosis and Myth in a Man-Made World.

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Cleghorn E. New York, NY: Dutton; 2021. ISBN: 9780593182956.

Women have been affected by implicit bias that undermines the safety of their care and trust in the medical system. This book shares the history anchoring the mindsets driving ineffective care for women and a discussion of the author’s long-term lupus misdiagnosis.

Wrong Site Surgery–Wrong Tooth Extraction.

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Farnborough, UK: Healthcare Safety Investigation Branch; April 22, 2021.

Wrong-site surgery in dentistry is a frequent and persistent never event. This report examines a case of pediatric wrong tooth extraction to reveal how the application of safety standards is influenced by the work environment and discusses the use of forcing functions to create barriers to error in practice.

Peer Review of a Report on Strategies to Improve Patient Safety.

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Washington DC: National Academies of Sciences, Engineering, and Medicine; 2021. ISBN: 9780309462808.

The Patient Safety and Quality Improvement Act of 2005 requires the Secretary of the U.S. Department of Health and Human Services (HHS), in consultation with the Director of the Agency for Healthcare Research and Quality, to prepare a report for Congress on effective strategies for reducing medical errors and increasing patient safety and on measures to encourage the appropriate use of such strategies. The Act also requires that a draft of the report be made available for public comment and review by the Institute of Medicine (now the National Academy of Medicine (NAM)). This publication reflects NAM’s review of the draft report. HHS is in the process of preparing a final report due to Congress in December 2021.

Investigation into Management of Venous Thromboembolism Risk in Patients Following Thrombolysis for an Acute Stroke.

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Farnborough, UK; Healthcare Safety Investigation Branch. October 13, 2020

Errors of omission in routine care can result in patient harm. This report discusses factors contributing to a pulmonary embolism in a recovering stroke patient acerbated by a lack of intended but omitted venous thromboembolism or VTE preventative care. The system improvement recommendations drawn from the incident analysis include that the UK National Health Service develop a standardized approach to VTE risk assessment and broad-based training to enable a cross-section of clinicians to use VTE prevention devices as required.

Making Complaints Count: Supporting Complaints Handling in the NHS and UK Government Departments.

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London, UK: The Parliamentary and Health Service Ombudsman; July 15, 2020. ISBN 9781528620666.

Patient and family complaints can provide insights into system weaknesses if managed effectively. This report examined complaint handling at the United Kingdom National Health Service. The analysis found that lack of training, consistency and learning orientation reduced the effectiveness of the effort.

Deficiencies in Care, Care Coordination, and Facility Response to a Patient Who Died by Suicide, Memphis VA Medical Center in Tennessee.

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Washington, DC: Department of Veterans Affairs, Office of Inspector General; September 3, 2020. Report No 19-09493-249.

Discontinuities in mental health care are a patient safety concern. This report analyzes how documentation gaps, medication reconciliation problems, and poor care coordination contributed to the suicide of a patient who presented at an emergency room, was screened there, and referred to a clinic for further care that was not completed.

Inadequate Emergency Department Care and Physician Misconduct at the Washington DC VA Medical Center.

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Office of the Inspector General. Washington, DC: Department of Veterans Affairs; July 28, 2020. Report Number 19-07507-214.

Patient suicide is a never event. This report analyzes the death of a veteran after presenting at an emergency room with suicidal ideation. The analysis found lack of both suicide prevention policy adherence and appropriate assessment, as well as a lack concern for the patient’s condition contributed to the failure.

First Do No Harm. The Report of the Independent Medicines and Medical Devices Safety Review.

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Implicit biases are known to affect the safety of health care. This analysis of the National Health Service (NHS) found weaknesses in NHS’ consideration of and response to women’s medication and medical device concerns. Among the recommendations submitted to improve patient centeredness and respect for patients are the establishment of central yet independent authority to serve as the conduit to address patient concerns and improve system safety accountability.

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