The goal of patient safety is to prevent harm to patients Mitchell (nd). Patient safety in any healthcare system is essential not only for the credibility of the system, but also for patient trust and satisfaction. Adverse outcomes are defined as any injury or harm resulting from medical care (Watcher, 2008). Undesirable consequences can lead to death and disability and cost the healthcare system. Bernard and Encinosa (2004) reported that in the United States, it costs twice as much to treat patients who have suffered adverse outcomes. The Institute of Medicine (IOM) (2000) reported that adverse outcomes cost the United States more than $16 billion, or 6% of total hospitalized patient costs. Therefore, adverse events are costly both in terms of human lives and financial resources. In In-Depth Analysis of What Went Wrong/Issues Impacting Healthcare Quality In reviewing this case study, the author is of the opinion that poor communication between the doctors treating this patient, limited L Patient assessment, provider bias/judgment, and inferior diagnostic procedures contributed to this adverse event. Poor Communication Continuous, clear, open, and transparent communication between physicians seeing the same patient is essential because it can reduce medical errors, improve the quality of care, and increase patient safety (Institute of Medicine, 2000). In this case study, no type of formal or informal communication between this patient's PCP, internist, and neurologist was reported. Evaluation In reviewing the medical care provided, it appears that the patient's medical history may have clouded her physician's decisions. For this reason, neither of his doctors chose to delve further into other possible reasons for his daily headaches. Many factors that should have been... middle of document ......5-6773.2006.00504.xJerant, AF and Hill, DB (2000). Does the use of electronic medical records improve surrogate patient outcomes in the outpatient setting? The Journal of Family Practice. 49 (4), 349-357. Kamaka, M. L. (2010). Designing a cultural competency program: asking stakeholders. Hawaii Medical Journal. 69 (3), 31-34. Institute of Medicine (2000). To err is human: Building a safer health system. Kohn L., Corrigan, J., Donaldson, M., eds. National Academy Press. Mitchell, PH (n.d.). Define patient safety and quality of care. Retrieved from http://www.ahrq.gov/qual/nurseshdbk/docs/MitchellP_DPSQ.pdfStrauss, SE, Richardson, WS, Glasziou, P., & Haynes, RB (2005). Evidence-Based Medicine: How to Practice and Teach EBM. (4th ed.). New York: Elsevier. Watcher, R. M. (2008). Understanding patient safety. New York; Hill McGraw