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Driessen RGH, Latten BGH, Bergmans DCJJ, et al. Virchows Arch. 2020;478(6):1173-1178.
Autopsies are an important tool for detecting misdiagnoses. Autopsies were performed on 32 septic individuals who died within 48 hours of admission to the intensive care unit. Of those, four patients were found to have class I missed major diagnosis. These results underscore the need to perform autopsies to improve diagnosis.
Holstine JB, Samora JB. Jt Comm J Qual Patient Saf. 2021;47(9):563-571.
Errors in surgical specimen handling can cause treatment delays or missed diagnoses. This children’s hospital implemented a quality improvement effort to reduce surgical specimen errors. Using a variety of methods, including changes to specimen labeling, improved communication, and specimen time-out, they were able to decrease the mean rate of order errors and labeling-related errors.

Office of Inspector General. June 2, 2021. Report No. 18-02496-157.

Health systems can exacerbate potential risk for patient harm due to clinician impairment and unprofessional activities. This report examines a long-term situation that, due to failure of reporting and other system issues, enabled over 3,000 diagnostic delay injuries stemming from specimen errors associated with one pathologist.
Scantlebury A, Sheard L, Fedell C, et al. Digit Health. 2021;7:205520762110100.
Electronic health record (EHR) downtime can disrupt patient care and increase risk for medical errors. Semi-structured interviews with healthcare staff and leadership at one large hospital in England illustrate the negative consequences of a three-week downtime of an electronic pathology system on patient experience and safety. The authors propose recommendations for hospitals to consider when preparing for potential technology downtimes.
Johnson SM, Samulski TD, O’Connor SM, et al. Am J Clin Pathol. 2021;Epub Mar 27.
Newly diagnosed cancer patients may request second opinions to confirm diagnosis, treatment, or prognosis. This study evaluated the pathology-specific reimbursement for cases originating at the primary site, a comprehensive cancer center, and cases originating at affiliate sites and referred to the cancer center for second opinions. Results confirmed that second opinions can reduce diagnostic errors and potentially lower costs of subsequent treatment; however, ways to improve the cost and process of receiving a second opinion should be explored.
Vijenthira S, Armali C, Downie H, et al. Vox Sang. 2021;116(2):225-233.
Transfusion errors can have serious consequences. This retrospective analysis used a Canadian national database to characterize patient registration-related errors in the blood transfusion process. Findings indicate that registration errors most commonly occur in outpatient areas and emergency departments and can lead to delays in transfusion.
Wright B, Lennox A, Graber ML, et al. BMC Health Serv Res. 2020;20(1):897.
Incomplete or delayed test result communication can contribute to diagnostic errors, delayed treatments and patient harm. The authors synthesized systematic and narrative reviews from multiple perspectives discussing diagnostic test result communication failures. The review identified several avenues for improving closed-loop communication through the use of technology, audit and feedback, and use of point-of-care or bedside testing.
Ferrara G, De Vincentiis L, Ambrosini-Spaltro A, et al. Am J Clin Pathol. 2021;155(1):64-68.
The COVID-19 pandemic has led to patients delaying or forgoing necessary health care.  Comparing the same 10-week period in 2018, 2019 and 2020, researchers used data from seven hospitals in northern-central Italy to assess the impact of COVID-19 on cancer diagnoses. Compared to prior years, cancer diagnoses overall fell by 45% in 2020. Researchers noted the largest decrease in cancer diagnoses among skin, colorectal, prostate, and bladder cancers.  
Harper A, Kukielka E, Jones RM. Patient Saf. 2020;2(3):14.
In an effort to identify process failures related to infectious disease spread in hospital settings, the authors analyzed patient safety events related to viruses and bacteria spread through respiratory droplets (e.g., pertussis, meningitis, measles) reported to the Pennsylvania Patient Safety Reporting System over a 12-month period. The analysis identified several process failures, most commonly involving the testing or processing of laboratory specimens and isolation-related procedures. The authors also discuss risk-reduction strategies to reduce the process failures contributing to the spread of infectious disease. These findings can assist organizations to develop strategies to reduce infection disease risk, which is important during the ongoing COVID-19 pandemic.

Ashworth S. Elemental. September 22, 2020.

The rate of autopsies – the “gold standard” of death investigation – are decreasing worldwide. This commentary highlights the lost opportunities for hospital and clinician learning from mistakes due this decline. The author ties the relevance of the loss to missed opportunities for understanding the effect of COVID-19 on the body to inform diagnostic, treatment and prevention activities.
Schiff GD, Mirica MM. Diagnosis (Berl). 2020;7(4):377-380.
This commentary discuses key issues related to diagnostic accuracy in the era of COVID-19, including considering differential diagnoses for COVID-19, the challenges of remote diagnoses, and the consequences of lapses in routine diagnostic and preventive care.
Lippi G, Simundic A-M, Plebani M. Clin Chem Lab Med. 2020;58(7):1070-1076.
This paper discusses potential vulnerabilities in the laboratory diagnosis of COVID-19, such as sample misidentification, inappropriate or inadequate sample collection, sample contamination, as well as the challenges to the diagnostic accuracy of current COVID-19 tests.

Malone P, Kamb L. Seattle pilot’s misdiagnosis highlights challenges around coronavirus testing. Seattle Times. March 30, 2020.

False negative test results can contribute to misdiagnosis, treatment delays, and patient and family trauma when the true diagnosis emerges. This story illustrates the impact of diagnosing an emerging disease when missteps can result in conditions that present dangers to the patients and the communities in which they live.
Cai H, Tu B, Ma J, et al. Med Sci Monit. 2020;26:e924171.
Production pressure – the pressure to continue to work at maximum capacity – presents risks to patient safety. This study reported on a survey of 534 healthcare providers and hospital staff in the Hunan province of China about the psychological impact of COVID-19. Respondents cited moral and social responsibility as being the strongest driver to continue working long hours during the outbreak and expressed anxiety and concerns regarding their safety, the safety of their families, and high mortality among their patients. Recognition of healthcare staff by hospital management and government, strong infection control guidelines, and specialized equipment and facilities for the management of COVID‑19 were reported as factors that mitigated psychological burnout.
This commentary involves two separate patients; one with a missing lab specimen and one with a mislabeled specimen. Both cases are representative of the challenges in obtaining and appropriately tracking lab specimens and the potential harms to patients. The commentary describes best practices in managing lab specimens.