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London, UK: Parliamentary and Health Service Ombudsman; July 18, 2016. ISBN: 9781474135764.
The National Health Service (NHS) has a history of sharing analyses of problems in its system. Summarizing an NHS investigation into the death of a 3-year-old boy, this report highlights the need to improve organizational culture, complaint follow-up, and transparency to reduce opportunities for similar incidents.
Journal Article > Study
Socio-technical issues and challenges in implementing safe patient handovers: insights from ethnographic case studies.
Balka E, Tolar M, Coates S, Whitehouse S. Int J Med Inform. 2013;82:e345-e357.
This ethnographic case study explored patient handoffs across different situations, including pre-hospital and primary care settings. These analyses emphasize numerous contextual issues that need be considered when creating computerized systems to support handoffs.