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Preventable Rash.
McLean C. AHRQ WebM&M [serial online]. March 2005.
At a routine clinic visit, screening labs are sent for a man with HIV. Not notified of the results, he assumes they are normal. One month later, he develops a classic syphilitic rash.
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Resource Type
Commentary
Setting of Care
Ambulatory Clinic or Office
Target Audience
Physicians
Clinical Area
Public Health
Safety Target
Diagnostic Errors
Missed or Critical Lab Results
Error Types
Noncognitive Errors ("Slips & Lapses")
Cognitive Errors ("Mistakes")
Approach to Improving Safety
Practice Guidelines
Communication between Providers
Laboratory Result Tracking Improvement
Origin/Sponsor
Agency for Healthcare Research and Quality (AHRQ)