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"Superficial" Report Leads to "Deep" Problem.
Dhaliwal G. AHRQ WebM&M [serial online]. December 2009.
Physicians confuse the terminology on a preliminary radiology report and diagnose a woman with foot and ankle pain as having a low-risk case of superficial vein thrombosis, rather than the more dangerous deep vein thrombosis she actually had.
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Inquiry into reporter's death finds multiple failures in care.
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Resource Type
Commentary
Setting of Care
Emergency Departments
Target Audience
Health Care Providers
Clinical Area
Emergency Medicine
Cardiology
Safety Target
Radiograph Interpretation Error
Venous Thrombosis and Thromboembolism
Error Types
Active Errors
Approach to Improving Safety
Communication between Providers
Forcing Functions