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Due to a series of incomplete signouts, information about a patient’s postoperative leg pain and chest discomfort is not conveyed to the primary team. A pulmonary embolism is discovered postmortem
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Utilizing information technology to mitigate the handoff risks caused by resident work hour restrictions.
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Setting of Care
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Discontinuities, Gaps, and Hand-Off Problems
Postoperative Surgical Complications
Approach to Improving Safety
Read Back Protocols
Duty Hour Limitation
Culture of Safety
Clinical Information Systems
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