Skip to main content

All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Narrow Results By
PSNet Original Content
Commonly Searched Resource Types
1 - 3 of 3
Singh H, Thomas EJ, Mani S, et al. Arch Intern Med. 2009;169:1578-1586.
Inadequate follow-up of diagnostic testing is a known safety issue in both hospital and ambulatory settings. Adoption of information technology approaches serves as a logical solution if designed to effectively notify providers of pending or necessary follow-up actions. This study used tracking software to determine if an electronic alert for abnormal imaging results was acknowledged and acted upon in a Veterans Affairs ambulatory setting. Investigators discovered that their seemingly fail-proof system, which included dual-alert communications, still led to persistent problems with missed test results. They also found that the dual-alert communication system was unexpectedly associated with a lack of timely follow-up. The authors advocate for greater multidisciplinary approaches to address these breakdowns.
Shojania KG, Fletcher KE, Saint S. Ann Intern Med. 2006;145:592-8.
This case study presents the events surrounding the death of a woman admitted to an academic medical center with pancreatitis. The discussion analyzes the sequence of errors that transpired from initial delays in diagnosis and treatment to poor communication and handoffs (the latter is a 2007 National Patient Safety Goal). The authors also explore the common yet unresolved tension in teaching hospitals for attending physicians who must provide appropriate supervision of trainees while also allowing autonomy for growth. This article is the last of a special collection entitled "Quality Grand Rounds," a series of articles published in the Annals of Internal Medicine that explores a range of quality issues and medical errors. An accompanying editorial (available via the link below) by the series editors reflects on the experiences of producing the 13 articles in this collection, the patient safety movement in general, and the importance of sharing these stories as educational tools to drive improvement.
Gandhi TK, Kachalia A, Thomas EJ, et al. Ann Intern Med. 2006;145:488-496.
Medical errors in the outpatient setting have remained a relatively understudied aspect of patient safety. This study analyzed data from malpractice claims at four liability insurers, similar to companion studies of errors in surgical and emergency department patients, to determine the frequency and causes of missed and delayed diagnoses. Diagnostic errors resulting in patient harm occurred in 181 cases, chiefly consisting of missed or delayed diagnoses of cancer. Failure to reach a timely diagnosis was generally due to multiple process breakdowns, including failure to order an appropriate diagnostic test and inadequate follow-up planning, many of which could be ascribed to physician cognitive errors. As with prior studies using chart review, reviewer's agreement on whether an error occurred was only moderate. The authors note that due to the complexity of contributing factors to outpatient errors, simple solutions are unlikely. An accompanying editorial, available via the link below, considers the differences in the nature of errors and approaches to solving them between the inpatient and outpatient settings and calls for greater attention to tackling outpatient safety issues.