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. American Hospital Association. Fast Facts on U.S. Hospitals, 2022. Available at https://www.aha.org/system/files/media/file/2022/01/fast-facts-on-US-hospitals-2022.pdf. Last accessed July 20, 2022.
4. Agency for Healthcare Research and Quality. AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2017 Available at https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/hacreport-2019.pdf. Last accessed July 20, 2022.
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 July 20, 2022.
6. The Joint Commission. Sentinel Events. Available at https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event. Last accessed July 20, 2022.
7. The Joint Commission. Sentinel Event Policy and Procedures. Available at https://www.jointcommission.org/sentinel_event_policy_and_procedures. Last accessed July 20, 2022.
8. Florida Legislature. The 2021 Florida Statutes: 395.0197 Internal Risk Management Program. Available at http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&URL=0300-0399/0395/Sections/0395.0197.html. Last accessed July 25, 2022.
9. Florida Agency for Health Care Administration. AHCA Incident Reporting System: Quarterly Report—Detail Data. Available at https://bi.ahca.myflorida.com/t/ABICC/views/QuarterlyReport_ASC-HOSP-HMO/DetailData. Last accessed July 25, 2022.
10. The Joint Commission. Quality and Safety: Sentinel Event Definition, Policy Revised. Available at https://www.jointcommission.org/-/media/tjc/newsletters/jc-online-july-21-2021.pdf. Last accessed July 20, 2022.
11. The Joint Commission. Sentinel Event Data: General Information and 2021 Update. Available at https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/sentinel-event-general-information-and-2021-update.pdf. Last accessed July 25, 2022.
12. American Academy of Orthopedic Surgeons. Information Statement: Surgical Site and Procedure Confirmation. Available at https://www.aaos.org/globalassets/about/bylaws-library/information-statements/1043-surgical-site-and-procedure-confirmation.pdf. Last accessed July 26, 2022.
13. The Joint Commission. Quick Safety 20: Strategies to Prevent URFOs (Updated May 2022). Available at https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety--issue-20-strategies-to-prevent-urfos/strategies-to-prevent-urfos. Last accessed July 25, 2022.
14. The Joint Commission. Performance of the Correct Procedure at the Correct Body Site. Available at https://cdn.who.int/media/docs/default-source/patient-safety/patient-safety-solutions/ps-solution4-performance-correct-procedure-at-correct-body-site.pdf?sfvrsn=9d29feb_6. Last accessed July 27, 2022.
15. The Joint Commission. The Universal Protocol. Available at https://www.jointcommission.org/standards/universal-protocol. Last accessed July 26, 2022.
16. The Joint Commission. Sentinel Event Alert 26: Delays in Treatment. Available at https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters/sentinel-event-alert-issue-26-delays-in-treatment. Last accessed July 25, 2022.
17. The Joint Commission. Sentinel Event Alert 12: Operative and Post-Operative Complications: Lessons for the Future. Available at https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters/sentinel-event-alert-issue-12-operative-and-post-operative-complications-lessons-for-the-future . Last accessed July 26, 2022.
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 https://www.nccmerp.org/about-medication-errors. Last accessed July 26, 2022.
21. The Joint Commission. Facts About the Official "Do Not Use" List of Abbreviations. Available at https://www.jointcommission.org/resources/news-and-multimedia/fact-sheets/facts-about-do-not-use-list. Last accessed July 26, 2022.
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. Academy of Managed Care Pharmacy. Medication Errors. Available at https://www.amcp.org/about/managed-care-pharmacy-101/concepts-managed-care-pharmacy/medication-errors. Last accessed July 26, 2022.
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 July 26, 2022.
27. Pozgar GD. Legal Aspects of Health Care Administration. 13th ed. Sudbury, MA: Jones & Bartlett Learning; 2018.
28. The Joint Commission. Sentinel Event Alert, Issue 39: Preventing Pediatric Medication https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/sea_39.pdf. Last accessed July 26, 2022.
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 April 17, 2024.
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.
33. Lydiatt DD. Cancer of the oral cavity and medical malpractice. Laryngoscope. 2010;112(5):816-819.
34. Pope JV, Edlow JA. Avoiding misdiagnosis in patients with neurological emergencies. Emergency Medicine International. 2012;(2012):949275.
35. Kamalian S, Kamalian S, Boulter DJ, Lev MH, Gonzalez RG, Schaefer PW. Stroke differential diagnosis and mimics: part 1. Applied Radiology. 2015;44(11):26-39.
36. Eswaran V, Wang RC, Vashi AA, Kanzaria HK, Fahimi J, Raven MC. Patient reported delays in obtaining emergency care during COVID19. Am J Emerg Med. 2022;56:306-309.
37. 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).
38. Suneja M, Beekmann SE, Dhaliwal G, Miller AC, Polgreen PM. Diagnostic delays in infectious diseases. Diagnosis (Berl). 2022;9(3):332-339.
39. Kobayashi T, Higgins Y, Melia MT, Auwaerter PG. Mistaken identity: many diagnoses are frequently misattributed to Lyme disease. Am J Med. 2022;135(4):503-511.
40. Tagarelli A, Lagonia P, Tagarelli G, Piro A. The European misdiagnosis of syphilis. Arch Dermatol. 2011;147(4):416.
41. Boussios S, Cooke D, Hayward C, et al. Metastatic spinal cord compression: unraveling the diagnostic and therapeutic challenges. Anticancer Res. 2018;38(9):4987-4997.
42. Mouliou DS. Managing viral emerging infectious diseases via current molecular diagnostics in the emergency department: the tricky cases. Expert Rev Anti Infect Ther. 2022;20(9):1163-1169.
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. Whang JS, Baker SR, Patel R, Luk L, Castro A 3rd. The causes of medical malpractice suits against radiologists in the United States. Radiology. 2013;266(2):548-554.
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. Williams SC, Schmaltz SP, Castro GM, Baker DW. Incidence and method of suicide in hospitals in the United States. Jt Comm J Qual Patient Saf. 2018;44(11):643-650.
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 https://www.ahrq.gov/questions/resources/20-tips.html. Last accessed July 27, 2022.
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. Cady RK, Farmer K. Migraine. In: Jay GW (ed). Clinicians Guide to Chronic Headache and Facial Pain. New York, NY: Informa Healthcare USA; 2010: 1-15.
57. Beithon J, Gallenberg M, Johnson K, et al. Diagnosis and Treatment of Headache. Bloomington, MN: Institute for Clinical Systems Improvement; 2013.
58. Mechcatie E. DDW: Study Finds Pancreatic Cancer Misdiagnosis Rate at 31%. Available at https://www.mdedge.com/gihepnews/article/101026/gastroenterology/ddw-study-finds-pancreatic-cancer-misdiagnosis-rate-31. Last accessed July 27, 2022.
59. Drossman DA. Functional gastrointestinal disorders: history, pathophysiology, clinical features, and Rome IV. Gastroenterology. 2016;150:1262-1279.
60. Drossman DA, Hasler WL. Rome IV-functional GI disorders: disorders of gut-brain interaction. Gastroenterology. 2016;150(6):1257-1261.
61. American Society of Health-System Pharmacists. ASHP Guidelines on Preventing Medication Errors in Hospitals. Available at https://www.ashp.org/-/media/assets/policy-guidelines/docs/guidelines/preventing-medication-errors-hospitals.ashx?la=en&hash=CFDD375E109297517C3CB96BDADE7B0D59E2560A. Last accessed July 27, 2022.
62. Graff-Radford SB. Facial pain, cervical pain, and headache. Continuum (Minneap Minn). 2012;18(4):869-882.
63. Lupoli TA, Lockey RF, Temporomandibular dysfunction: an often overlooked cause of chronic headaches. Ann Allergy Asthma Immunol. 2007;99(4):314-318.
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.
Mention of commercial products does not indicate endorsement.