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Cases & Commentaries
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Yael K. Heher, MD, MPH; November 2017
A resident entered orders into the EHR for a biopsy specimen of a patient's rash to be sent to pathology for evaluation. The biopsy specimen was delivered to the laboratory without a copy of the orders. Because pathology and the medicine service did not share the same EHR, the laboratory could neither view the orders nor direct the biopsy to the appropriate area for analysis without a printed copy. The next day, the resident attempted to look up the results but found none.
Journal Article > Study
Steelman VM, Williams TL, Szekendi MK, Halverson AL, Dintzis SM, Pavkovic S. Arch Pathol Lab Med. 2016;140:1390-1396.
Errors related to the handling of surgical specimens can lead to serious patient harm in the form of delayed and missed diagnoses as well as repeat procedures. In this retrospective review, researchers looked at 648 reported adverse events and near misses involving surgical specimen management. They found that all steps of the specimen handling process are subject to error, but specimen labeling, collection, and transport represented the most frequently reported incidents. Additionally, 52 of the events led to the need for further treatment or to patient harm. The authors suggest that to enhance the safety of specimen handling, organizations should develop standard processes, provide training for staff, improve communication and handoffs, and consider the use of technological systems that might facilitate tracking of specimens.
Journal Article > Study
Mitigation of patient harm from testing errors in family medicine offices: a report from the American Academy of Family Physicians National Research Network.
Graham DG, Harris DM, Elder NC, et al. Qual Saf Health Care. 2008;17:201-208.
Patient harm resulting from errors in the diagnostic testing process is common in outpatient care, but many potentially harmful errors become "near misses" due to mitigating actions by clinicians, office staff, or patients themselves. This study analyzed voluntary incident reports from a companion study of testing errors in family medicine clinics, with the goal of identifying factors that prevented patient harm from testing errors. Errors were more likely to be mitigated if they could be more easily detected by office staff—for example, if a test was ordered incorrectly—and mitigated events resulted in less harm to patients. However, as noted in prior research, problems were noted at each stage of the testing process, implying that ambulatory clinics require comprehensive systems for ordering and following up on tests to ensure patient safety and optimal care.