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St. Paul, MN: Minnesota Department of Health; March 2019.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2018 report summarizes information about 384 adverse events that were reported and found pressure ulcers and invasive procedure events increased, while fall-related deaths decreased. Reports from previous years are also available.
Oakbrook Terrace, IL: Joint Commission Resources; 2010. ISBN: 9781599404097.
This guide discusses the impact of poor communication on care transitions and describes tactics for improvement.
London, UK: National Patient Safety Agency; 2009. ISBN: 9781906624088.
This publication analyzes 72,482 medication incidents reported to the National Health Service and highlights areas for improvement and prevention.