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International Journal for Quality in Health Care 13:423-424 (2001)
© 2001 International Society for Quality in Health Care

Every Defect is a Treasure

Inadequate transmission of patient information across a continuum of care environments precedes a fatal outcome

Kathleen Dwyer

The Risk Management Foundation of the Harvard Medical Institutions, Cambridge, Massachusetts, USA.

A 47-year-old woman with a long-standing history of abdominal pain is urgently admitted to a hospital after being seen on four consecutive days in various settings, and dies while being intubated for a small bowel obstruction.


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