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Cases & Commentaries
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Vanitha Janakiraman Mohta, MD; February 2012
A pregnant woman with new onset hypertension and proteinuria was admitted to the hospital for further testing. Test results for a 24-hour urine collection were initially reported as normal in the electronic medical record, and discharge planning was begun. However, a later amended report showed the results were elevated and abnormal, confirming a diagnosis of preeclampsia.
Journal Article > Study
Raab SS, Grzybicki DM, Zarbo RJ, et al. Am J Clin Pathol. 2007;128:817-824.
This AHRQ-funded study of cervical cancer screening results found a remarkably low incidence of missed malignancies. The authors analyzed Papanicolaou test results and the results of subsequent biopsies and found that the results were discordant in only 0.3% of cases, with most of these inconsistencies being clinically insignificant. Delayed diagnosis of cancer is a common cause of malpractice suits in ambulatory care. Although a prior study by Raab and colleagues found a higher overall error rate in anatomic pathology cancer diagnosis, this study documents that the US cervical cancer screening system appears to be very effective at preventing squamous cervical cancer. However, a systematic review of missed or delayed cancer diagnoses found that misdiagnosis of four common types of cancer—melanoma, as well as cancer of the breast, lung, or colon—remains common.
Journal Article > Commentary
ACOG Committee on Patient Safety and Quality Improvement. Obstet Gynecol. 2012;120:1535-1537.
Cullen A. Uitgeverij van Brug: The Hague, The Netherlands; 2019. ISBN: 9789065232236.
Patient stories offer important insights regarding the impact medical errors have on patients and their families. This book shares the author's experience with medical error and spotlights how lack of transparency in European health care can contribute to avoidable process failures that result in patient harm.