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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.
Journal Article > Study
Astion ML, Shojania KG, Hamill TR, Kim S, Ng VL. Am J Clin Pathol. 2003;120:18-26.
The investigators describe a system for classifying errors in clinical laboratories.