In Portland, many patients are dealing with complex care right before and after hospital visits—urgent conditions, comorbidities, and frequent transitions between providers. That makes the sequence of events especially important:
- triage decisions and escalation (when symptoms worsen)
- medication administration and monitoring
- test ordering, results review, and communication
- discharge timing and follow-up instructions
- handoffs between shifts, units, and specialty teams
Even small gaps—an overlooked lab result, delayed recognition of deterioration, incomplete discharge planning—can become central to whether a preventable injury occurred.


