Novel analysis of clinically relevant diagnostic errors in point-of-care devices.
Approach to Improving Safety
- Device-related Complications
- Diagnostic Errors
- Medication Errors/Preventable Adverse Drug Events
Setting of Care
In this study, investigators compared international normalized ratio measurements (INR, a measurement of blood clotting ability) obtained simultaneously on a point-of-care analyzer and a standard blood draw. Although the concordance between the two measurements met traditional quality assurance standards, the point-of-care analyzer results were systematically biased toward normal measurements, putting patients at risk of preventable adverse events due to failure to adjust anticoagulant medications appropriately.