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System weaknesses are often at the root of never events. This news story discusses the suicide of a concussed woman whose care failed due to gaps in team communication, discharge and transition practices.

Patient suicide is considered a sentinel event. This feature shares an examination of approximately 100 preventable deaths in the State of California over a decade. An examination of the case records identified breakdowns in care processes such as lack of training, low staffing and human error.

Psychiatric patients are vulnerable to particular safety hazards. This news article reports on unintended consequences associated with a strategy to help patients adapt to being discharged home by providing passes for them to adjust to independent living.

Discussing a case of patient suicide, this news article explores the lack of transparency around patient safety incidents in the state of Georgia.

This news piece details efforts to collect, analyze, and utilize state-wide reports on health care–associated infections in Pennsylvania.