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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.
Carpenter D, Famolaro T, Hassell S, et al. Cambridge, MA: Institute for Healthcare Improvement; 2017.
The ambulatory environment presents unique situations that can introduce safety challenges into care processes. This report explores factors in home-based care that can affect patient safety, including insufficient household readiness for patients and poor communication between caregivers, patients, and the medical team. The authors recommend areas of research to address the gaps in understanding how to improve patient safety in the home.