26
Vol. 66, No. 1 2015
Northeast Florida Medicine
CME
• An effective, appropriate hand-off/sign-out system.
• For inpatients, reassessment throughout hospital-
ization with a thorough examination at discharge.
• Consistent adherence with “Universal Protocols”
before the first incision for every procedure.
v
References
1. Sandra G. Boodman,
The Pain of Wrong Site Surgery,
Washington Post Newspaper
, January 21, 2011
2. Diane Rydrych, MA; Julie Apold, MA; and Kathleen
Harder, PhD. Preventing wrong-site surgery in Min-
nesota: A 5-year journey.
Patient Safety and Quality
Healthcare
, November / December 2012.
3. Mark Chassin, MD, Mary Cooper MD, Lisa Lewis,
RN, and Rudy Manthei, MD Presented at the Joint
Commission Center for Transforming Healthcare
Conference, June 29, 2011
4. Philip F. Stahel, M.D, et. al. Wrong-Site and Wrong-Pa-
tient Procedures in the Universal Protocol Era: Analysis
of a Prospective Database of Physician Self-reported Oc-
currences, (JAMA) Archives of Surgery October, 2010
5. Kaiser Health News, The Henry J. Kaiser Family
Foundation, June 2011
6. “Health Reporter” (United Kingdom), Thursday,
December 12, 2013
7. Mike Durkin, MD
December
12, 2013,
8. Cynthia Berg, MD, Isabella Danel, MD Hani Atrash,
MD, Suzanne Zane, DVM, Linda Bartlett, MD.
Strategies to reduce pregnancy-related deaths from
identification and review to action, Centers for Dis-
ease Control and Prevention Division of Reproductive
Health Safe Motherhood Activity.
9. Heron MP, et. al. Final data for 2006. National Center
for Health Statistics,
National Vital Statistics Reports
57(14), 2009
10. Sentinel Event Alert, The Joint Commission, Issue 44.
January 26, 2010
11. SE Geller, et al. A descriptive model of preventability
in maternal morbidity and mortality.
Journal of Perina-
tology
, 2006, (26(2):79-84).
12. S. Gorman, MD
New England Medical Journal.
March 5, 2013
13. Centers for Disease Control and Prevention (CDC).
Pregnancy-related mortality surveillance. Surveillance
Summaries, Morbidity and Mortality Weekly Report,
February 21, 2003, 2003:52.
14. Berg CJ, et al. Pregnancy-related mortality in the
United States, 1991-1997. Obstetrics & Gynecology,
2003, 101(2):289-296. Heron MP, et al. Deaths: Final
data for 2006. National Center for Health Statistics,
National Vital Statistics Reports,
57(14), 2009.
15. Geller SE, et al. The continuum of maternal morbidity
and mortality: Factors associate with severity.
American
Journal of Obstetrics & Gynecology,
2004, 191(3):939-
944.
16. Adverse health care events reporting system: what have
we learned? A 5-year review. Minnesota Department
of Health, January 2009.
17. Gordon D. Schiff, et al. Diagnosing Diagnosis Errors:
Lessons from a Multi-institutional Collaborative Proj-
ect, Advances in patient safety. Agency for Healthcare
Quality, Vol 2.256, February 2005
18. Kevin Helliker and Thomas Burton Deadly Discrep-
ancy: New Light on Aortic Aneurysms February 2004
19. “The Doctor’s Practice” the Doctors Company Medi-
cal Malpractice Company, September 2013
20. Staniland JR et al. Clinical presentation of acute abdo-
men: study of 600 patients. BMJ 1972; 3(5823):393-8.
21. Rusnak RA et al. Misdiagnosis of acute appendicitis:
common features discovered in cases after litigation.
American Journal of Emergency Medicine
1994;
12(4):397-402.
22. Brewster GS et al. Medical Myth: Analgesia should
not be given to patients with an acute abdomen,
West-
ern Journal of Medicine
2000; 172(3):209-10.
23. Wolfe JM et al. Does morphine change the physical
examination in patients with acute appendicitis?
Amer-
ican Journal of Emergency Medicine
2004; 22(4):280-5.
24. Thomas SH et al. Effects of morphine analgesia on di-
agnostic accuracy in Emergency Department patients
with abdominal pain: a prospective, randomized trial.
J American College of Surgery
2003; 196(1):18-31.
25. Daniel M. Feinberg, MD. Measurement as an essential
step in patient safety. Patient Safety Colloquium:
Communications in Patient Safety: It’s A No-Brainer,
April 2, 2006.
