Works Cited

1. Committee on Quality of Health Care in American. To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press; 1999.

2. Makary MA, Daniel M. Medical error: the third leading cause of death in the U.S. BMJ. 2016;353:i2139.

3. Centers for Disease Control and Prevention. Hospital Utilization (in Non-Federal Short-Stay Hospitals). Available at http://www.cdc.gov/nchs/fastats/hospital.htm. Last accessed August 1, 2016.

4. Agency for Healthcare Research and Quality. Efforts To Improve Patient Safety Result in 1.3 Million Fewer Patient Harms: Interim Update on 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013. Available at http://www.ahrq.gov/professionals/quality-patient-safety/pfp/interimhacrate2013.html. Last accessed August 1, 2016.

5. Florida Statutes. 456.013 Department; General Licensing Provisions. Available at http://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0400-0499/0456/Sections/0456.013.html. Last accessed August 1, 2016.

6. The Joint Commission. Sentinel Events. Available at http://www.jointcommission.org/assets/1/6/CAMH_2012_Update2_24_SE.pdf. Last accessed August 1, 2016.

7. The Joint Commission. Sentinel Event Policy and Procedures. Available at https://www.jointcommission.org/sentinel_event_policy_and_procedures/. Last accessed August 1, 2016.

8. Florida Legislature. The 2016 Florida Statutes: 395.0197 Internal Risk Management Program. Available at http://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0300-0399/0395/Sections/0395.0197.html. Last accessed August 1, 2016.

9. Florida Agency for Health Care Administration. Code 15 Report Totals by Category of Injury. Available at http://ahca.myflorida.com/. Last accessed August 2, 2016.

10. The Joint Commission. Most Commonly Reviewed Sentinel Event Types. Available at https://www.jointcommission.org/assets/1/18/Event_type_2Q_2016.pdf. Last accessed August 2, 2016.

11. The Joint Commission. Sentinel Event Data: General Information. Available at https://www.jointcommission.org/sentinel_event_data_general. Last accessed August 2, 2016.

12. American Academy of Orthopedic Surgeons. Information Statement: Surgical Site and Procedure Confirmation. Available at http://www.aaos.org/CustomTemplates/Content.aspx?id=22291&ssopc=1. Last accessed August 2, 2016.

13. The Joint Commission. Preventing unintended retained foreign objects. Sentinel Event Alert. 2013;51:1-5.

14. The Joint Commission. Performance of the Correct Procedure at the Correct Body Site. Available at http://www.who.int/patientsafety/solutions/patientsafety/PS-Solution4.pdf. Last accessed August 2, 2016.

15. The Joint Commission. Universal Protocol. Available at https://www.jointcommission.org/standards_information/up.aspx. Last accessed August 2, 2016.

16. The Joint Commission. Quick Safety: Preventing Delays in Treatment. Available at https://www.jointcommission.org/issues/article.aspx?Article=qiDq9ABqL5P%20JvIVVbvCetbRt4FiwbTAKELAcCSjJUs=. Last accessed August 2, 2016.

17. AHC Media. JCAHO Data Show Surgical Complications, Causes. Available at http://www.ahcmedia.com/articles/45354-jcaho-data-show-surgical-complications-causes. Last accessed August 2, 2016.

18. The Joint Commission. Detecting and treating suicide ideation in all settings. Sentinel Event Alert. 2016;56:1-7.

19. The Joint Commission. Preventing falls and fall-related injuries in health care facilities. Sentinel Event Alert. 2015;55:1-5.

20. National Coordinating Council for Medication Error Reporting and Prevention. About Medication Errors. Available at http://www.nccmerp.org/about-medication-errors. Last accessed August 2, 2016.

21. The Joint Commission. Facts About the Official "Do Not Use" List of Abbreviations. Available at https://www.jointcommission.org/facts_about_do_not_use_list/. Last accessed August 2, 2016.

22. Cohen MR (ed). Medication Errors. 2nd ed. Washington, DC: American Pharmacists Association; 2007.

23. Flynn EA, Barker KN, Carnahan BJ. National observational study of prescription dispensing accuracy and safety in 50 pharmacies.J Am Pharm Assoc (Wash). 2003;43(2):191-200.

24. O'Donnell J, Vogenberg FR. Legal risk management opportunities, pharmacy practice, and P&T committees. Part 1: deconstructing dispensing errors. P T. 2014;39(8):559-562, 579.

25. Breland BD. Strategies for the prevention of medication errors. Hospital Pharmacy Report. 2000;14(8):56-65.

26. Federico F. The Five Rights of Medication Administration. Available at http://www.ihi.org/resources/pages/improvementstories/fiverightsofmedicationadministration.aspx. Last accessed August 2, 2016.

27. Pozgar GD. Legal Aspects of Health Care Administration. 11th ed. Sudbury, MA: Jones & Bartlett Learning; 2012.

28. The Joint Commission. Sentinel Event Alert, Issue 39: Preventing Pediatric Medication Errors. Available at http://www.jointcommission.org/assets/1/18/SEA_39.pdf. Last accessed August 2, 2016.

29. Florida Administrative Code. 64B8-13.005. Continuing Education for Biennial Renewal. Available at https://www.flrules.org/gateway/ruleno.asp?id=64B8-13.005. Last accessed May 18, 2018.

30. Zarick AL. Leadership in Legal Education Symposium X. Damage deferred: determining when a cause of action begins to accrue for a cancer misdiagnosis claim. Univ Toledo Law Rev. 2010;41:445.

31. Lyratzopoulos G, Vedsted P, Singh H. Understanding missed opportunities for more timely diagnosis of cancer in symptomatic patients after presentation. Br J Cancer. 2015;112(Suppl 1):S84-S91.

32. Lydiatt DD. Medical malpractice and cancer of the larynx. Laryngoscope. 2010;112(3):445-448.

33. Lydiatt DD. Cancer of the oral cavity and medical malpractice. Laryngoscope. 2010;112(5):816-819.

34. Zhan C, Miller MR. Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. JAMA. 2003;290:1868-1874.

35. Thompson JS, Baxter BT, Allison JG, Johnson FE, Lee KK, Park WY. Temporal patterns of postoperative complications. Arch Surg. 2003;138(6):596-602.

36. Kahn RL, Stanton MA, Tong-Ngork S, Liguori GA, Edmonds CR, Levine DS. One-year experience with day-of-surgery pregnancy testing before elective orthopedic procedures. Anesth Analg. 2006;106(4):1127-1131.

37. American Society of Anesthesiologists Task Force on Pre-Anesthesia Evaluation. Practice advisory for pre-anesthesia evaluation. Anesthesiology. 2002;96:485-496.

38. Palmer SK, Van Norman GA, Jackson SL. Routine pregnancy testing before elective anesthesia is not an American Society of Anesthesiologists standard. Anesth Analg. 2009;108(5):1715-1716.

39. Tenore JL. Ectopic pregnancy. Am Fam Physician. 2000;61(4):1080-1088.

40. Sepilian VP, Wood E. Ectopic Pregnancy. Available at https://emedicine.medscape.com/article/258768-overview. Last accessed July 13, 2018.

41. Amsterdam E, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes. J Am Coll Cardiol. 2014;64(24):e139-e228.

42. Gracia CR, Barnhart KT. Diagnosing ectopic pregnancy: decision analysis comparing six strategies. Obstet Gynecol. 2001;97(3):464-470.

43. Roffi M, Patrono C, Collet JP, et al. 2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). Eur Heart J. 2016;37(3):267-315.

44. Mosca L, Benjamin EJ, Berra K, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women—2011 update: a guideline from the American Heart Association. Circulation. 2011;123(11):1243-1262.

45. El-Menyar A, Zubaid M, Sulaiman K, et al. Atypical presentation of acute coronary syndrome: a significant independent predictor of in-hospital mortality. J Cardiol. 2011;57(2):165-171.

46. Khan NA, Daskalopoulou SS, Karp I, et al. Sex differences in acute coronary syndrome symptom presentation in young patients. JAMA Intern Med. 2013;173(20):1863-1871.

47. Darawshe A, Rabkin Y, Batsheva Z, Abdelhadi F, Feldman A, Rosenfeld R. Misdiagnosed acute coronary syndrome: characteristics of patients with acute coronary syndrome discharged home from the emergency department. Israeli Journal of Emergency Medicine. 2007;7(3):3-10.

48. Dahlöf C, Maassen Van Den Brink A. Dihydroergotamine, ergotamine, methysergide and sumatriptan: basic science in relation to migraine treatment. Headache. 2012;52(4):707-714.

49. Cooke LJ, Becker WJ. Migraine prevalence, treatment and impact: the Canadian Women Migraine Study. Can J Neurol Sci. 2010;37(5):580-587.

50. Graff-Radford SB. Facial pain, cervical pain, and headache. Continuum (Minneap Minn). 2012;18(4):869-882.

51. Rinke ML, Bundy DG, Velasquez CA, et al. Interventions to reduce pediatric medication errors: a systematic review. Pediatrics. 2014;134(2):338-360.

52. Gillespie LD, Robertson MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2012;(9):CD007146.

53. Agency for Healthcare Research and Quality. 20 Tips to Help Prevent Medical Errors: Patient Fact Sheet. Available at http://www.ahrq.gov/patients-consumers/care-planning/errors/20tips/index.html. Last accessed August 2, 2016.

54. Lupoli TA, Lockey RF, Temporomandibular dysfunction: an often overlooked cause of chronic headaches. Ann Allergy Asthma Immunol. 2007;99(4):314-318.

55. Cady RK, Farmer K. Migraine. In: Jay GW (ed). Clinician's Guide to Chronic Headache and Facial Pain. New York, NY: Informa Healthcare USA; 2010: 1-15.

56. Beithon J, Gallenberg M, Johnson K, et al. Diagnosis and Treatment of Headache. Bloomington, MN: Institute for Clinical Systems Improvement; 2013.

57. McDonald C, Hernandez M, Gofman Y, Suchecki S, Schreier W. The five most common misdiagnoses: a meta-analysis of autopsy and malpractice data. Internet J Fam Pract. 2008;7(2).

58. Deaño RC, Glassner-Kolmin C, Rubenfire M, et al. Referral of patients with pulmonary hypertension diagnoses to tertiary pulmonary hypertension centers: the multicenter RePHerral study. JAMA Intern Med. 2013;173(10):887-893.

59. Lahey MB; Graul A, Meyers S, Ferrarello D, Oxford CM. Keeping our newborns safe: effectively decreasing the rate of neonatal falls during the postpartum period. Obstetrics & Gynecology. 2015;125(Suppl 1):108S-109S.

60. Jabbarpour YM, Jayaram G. Suicide risk: navigating the failure modes. Quality and Professionalism in Psychiatry. 2011;9(2):186-193.

61. American Society of Health-System Pharmacists. ASHP Guidelines on Preventing Medication Errors in Hospitals. Available at http://www.ashp.org/doclibrary/bestpractices/medmisgdlhosp.aspx. Last accessed August 2, 2016.

62. Poon EG, Kachalia A, Puopolo AL, Gandhi TK, Studdert DM. Cognitive errors and logistical breakdowns contributing to missed and delayed diagnoses of breast and colorectal cancers: a process analysis of closed malpractice claims. J Gen Intern Med. 2012;27(11):1416-1423.

63. Pope JV, Edlow JA. Avoiding misdiagnosis in patients with neurological emergencies. Emergency Medicine International. 2012;(2012):949275.

64. Newman-Toker DE, Moy E, Valente E, Coffey R, Hines AL. Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based sample. Diagnosis. 2014;1(2):155-166.


Copyright © 2016 NetCE, P.O. Box 997571, Sacramento, CA 95899-7571
Mention of commercial products does not indicate endorsement.