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Cases & Commentaries
- Web M&M
Bryan A. Liang, MD, PhD, JD; May 2004
Understanding that she may lose her life without it, a woman severely injured in a collision rejects a blood transfusion for religious reasons. However, her parents persuade the physicians otherwise, and the woman lives.
Dobbs D. New York Times Magazine. April 24, 2005;sect 6:40.
The author interviews experts who discuss the autopsy as a unique method for discovering medical mistakes and why it is not used more often as a teaching and improvement mechanism.
Landro L. Wall Street Journal (Eastern edition). June 14, 2006:D1. [Reprinted on Post-gazette.com].
This article reports on a laboratory mix-up resulting in misdiagnosis and unneeded surgery and discusses the problem of laboratory errors.
Journal Article > Commentary
Davis Giardina T, Singh H. JAMA. 2011;306:2502-2503.
This commentary discusses a federal proposal to provide patients with direct access to laboratory test results as a tactic to reduce errors.
Landro L. Wall Street Journal. January 17, 2012:D1.
This newspaper article discusses second opinions as a tactic for catching diagnostic errors.
Saul S. New York Times. July 19, 2010;A1.
This newspaper article investigates diagnostic errors in breast cancer through the story of a patient who was misdiagnosed. Concern about the accuracy of pathology for early stages of disease and ductal carcinoma in situ has experts debating the best mechanisms to ensure competency and reliability in this field.
Gabler E. Milwaukee Journal Sentinel. May 15, 2015.
Reporting on weaknesses in laboratory testing methods, this news article discusses patients' experiences with testing errors to illustrate how such failures can contribute to patient harm—such as missed or delayed diagnosis—and raises concerns about insufficient transparency, investigations, and regulations around laboratory facilities with poor processes.
Shell ER. Sci Am. 2015;313(5):28-29.
Jauhar S. New York Times. March 3, 2016.
Performance of autopsies, previously considered an essential learning tool for clinicians, has decreased in recent years due to insufficient funding to cover costs and lack of physician endorsement of the practice. This newspaper article provides insights from a physician regarding how the decline in autopsies could affect care and highlights the benefits of autopsies in light of the current emphasis on improving diagnosis.
Journal Article > Study
Patient groups, clinicians and healthcare professionals agree—all test results need to be seen, understood and followed up.
Dahm MR, Georgiou A, Herkes R, et al. Diagnosis (Berl). 2018;5:215-222.
Inadequate test result follow-up places patients at risk of delayed diagnosis, especially in the ambulatory setting. Diverse stakeholders in Australia established an agenda for enhancing test result management, which included better governance, improved use of technology, and consistent patient engagement. A WebM&M commentary explored two incidents where poor test result follow-up led to patient harm.