Washington, DC: VA Office of the Inspector General; June 28, 2022. Report No 21-03349-186.
This WebM&M describes a 78-year-old veteran with dementia-associated aggressive behavior who was hospitalized multiple times over several months for hypoxic respiratory failure and atrial fibrillation before being discharged to a skilled nursing facility. The advanced care planning team, in consultation with palliative care and ethics experts, determined that transition to hospice was appropriate. However, these recommendations were verbally communicated and not documented in the chart.
Farnborough, UK: Healthcare Safety Investigation Branch; June 2022.
Arora V, Farnan J. UpToDate. June 15, 2022.
Järvinen TLN, Rickert J, Lee MJ. Clin Orthop Relat Res. 2013-2022.
This WebM&M describes two incidences of the incorrect patient being transported from the Emergency Department (ED) to other parts of the hospital for tests or procedures. In one case, the wrong patient was identified before undergoing an unnecessary procedure; in the second case, the wrong patient received an unnecessary chest x-ray. The commentary highlights the consequences of patient transport errors and strategies to enhance the safety of patient transport and prevent transport-related errors.