The goal of patient safety is to prevent harm to patients Mitchell (nd). Patient safety in any healthcare system is critical not only to the credibility of the system, but also to patient trust and satisfaction. Adverse outcomes are defined as any injury or harm resulting from medical care (Watcher, 2008). Adverse outcomes can cause death and disability and cost the healthcare system dearly. Bernard and Encinosa (2004) reported that in the United States it costs twice as much to treat patients who have had adverse outcomes. The Institute of Medicine (IOM) (2000) reported that adverse outcomes cost the United States more than $16 billion, or 6% of total hospital costs. Therefore, adverse events are costly in terms of both human lives and financial resources. patient assessment, provider bias/judgment, and inferior diagnostic procedures contributed to this adverse event. Poor communication Continuous, clear, open and transparent communication between doctors who see the same patient is essential as this can reduce medical errors, improve the quality of care and increase patient safety (Institute of Medicine, 2000). In this case study, no formal or informal communication was reported between this patient's primary care physician, internist, and neurologist. Evaluation When reviewing the medical care provided, it appears that the patient's prior medical history clouded her doctor's decisions. For this reason, none of his doctors decided to delve into other possible reasons for his daily headaches. Many factors that should have been… half of the paper… 5-6773.2006.00504.xJerant, AF, & Hill, DB (2000). Does the use of electronic health 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 competence curriculum: Asking stakeholders.Hawaii Medical Journal. 69 (3), 31-34. Institute of Medicine (2000). To err is human: building a safer healthcare system. Kohn L., Corrigan, J., Donaldson, M., eds. National Academy Press.Mitchell, P.H. (n.d.). Define patient safety and quality of care. Retrieved from http://www.ahrq.gov/qual/nurseshdbk/docs/MitchellP_DPSQ.pdfStrauss, S. E., Richardson, W. S., Glasziou, P., & Haynes, R. B. (2005). Evidence-based medicine: How to practice and teach EBM. (4th ed.). New York: Elsevier. Watcher, R. M. (2008). Understand patient safety. New York; McGraw Hill