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Cases & Commentaries
- Web M&M
Marcelle I. Cedars, MD; January 2004
A pregnant woman arrives at the ED with severe abdominal pain. Concerned about a ruptured appendix, the ED physicians order a CT scan. The obstetrics resident examines her there and is concerned about a ruptured heterotopic pregnancy.
Journal Article > Review
Pfeifer R, Pape HC. Patient Saf Surg. 2008;2:20.
This review found that missed injuries and delayed diagnoses occur frequently, with many of the missed injuries being clinically significant. The authors call for standardized studies using comparable definitions of such injuries.
Journal Article > Study
Kaplan LJ, Maerz LL, Schuster K, et al. J Trauma. 2009;67:173-179.
Since adoption of the 2003 ACGME duty hour restrictions, targeted curricular and information technology initiatives have emerged to address safe handoffs in care. This study analyzed surgical rapid response team (RRT) calls to determine if greater discontinuity in care was a potentially contributing factor. Investigators found that impending respiratory failure and acute volume overload were the most common conditions prompting RRT activation. However, the more noteworthy findings were that RRT activations most frequently occurred during times of cross-coverage, resulted from team-based errors of omission, and were frequently preventable or potentially preventable events. A past AHRQ WebM&M commentary discussed a case of a failed signout process that contributed to a delay in treatment and diagnosis.