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Cases & Commentaries
- Web M&M
John Q. Young, MD, MPP; July 2011
A healthy elderly man presented to his primary care doctor—a third-year internal medicine resident—for routine examination. A PSA test was markedly elevated, but the results came back after the resident had graduated, and the alert went unread. Months later, the patient presented with new onset low back pain and was diagnosed with metastatic prostate cancer.
Perspectives on Safety > Perspective
with commentary by Richard J. Baron, MD, The Business Case for Improving Safety, May 2009
Most patient interactions with the health care system occur in the outpatient setting. Many potential and actual safety problems occur there as well.(1) Yet patient safety literature and practice do not seem to have reached deeply into ambulatory care. This is likely due to a combination of factors: in most practices, there is no layer of administration providing a second look at routine policies and procedures; there is no accrediting agency, like The Joint Commission, to mandate safe practices (2); and those of us in office practice are so consumed with simply getting through the day that it is difficult to recognize the problems, large and small, that can lead to major safety hazards. The business case for safety, such as it is, relies almost entirely on the malpractice rate-setting process: errors that result in litigation lead to higher premiums and personal and professional misery. However, as Studdert (3) has argued, relying on the malpractice system to identify and "correct" errors is unlikely to be timely or productive.
Journal Article > Commentary
Cosford PA, Thomas JM. BMJ. 2010;340:c3194.
This commentary analyzes a fatal medication overdose by a foreign physician providing care after hours in the United Kingdom and offers recommendations for safe out-of-hours care including tips to improve teamwork, competency verification, and medical record access.
Journal Article > Study
The management of test results in primary care: does an electronic medical record make a difference?
Elder NC, McEwen TR, Flach J, Gallimore J, Pallerla H. Fam Med. 2010;42:327-333.
Electronic health records (EHRs) hold great promise for improving patient safety, but remain underutilized, especially in ambulatory care settings. Failure to appropriately follow up on abnormal test results is a common ambulatory care safety problem, and has been implicated in malpractice lawsuits arising from missed or delayed diagnoses. In this study conducted at eight family medicine clinics, those with an EHR documented clinician and patient notification of abnormal test results and clear follow-up plans more often than those with paper charts. However, even in clinics using EHRs, more than one-third of abnormal results had no follow-up plan documented. This finding corroborates prior research that clinician notification alone does not ensure timely and complete follow-up of test results.
Tools/Toolkit > Government Resource
Itasca, IL: American Academy of Pediatrics; 2018.
Diagnostic error prevention in primary care is a persistent challenge. This AHRQ-funded toolkit provides guidance for ambulatory care organizations that seek to improve the reliability of diagnosis in children. The material focuses on tactics to enhance how practices recognize, track, and follow up on adolescent depression, pediatric elevated blood pressure, and actionable laboratory results.