Important Information About NetCE's Response to COVID-19

Complete Your CE

Special OffersCourse ListCE RequirementsHave Questions? See Our FAQs.

Works Cited

Medical Error Prevention and Root Cause Analysis

Course #51334-

2
  • Back to Course Home
  • Participation Instructions
    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.
Complete for Credit
Read Course Content

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.

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. 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.

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

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

  • Back to Course Home
  • Participation Instructions
    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.
Complete for Credit
Read Course Content