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Cases & Commentaries
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Catherine McLean, MD; March 2005
At a routine clinic visit, screening labs are sent for a man with HIV. Not notified of the results, he assumes they are normal. One month later, he develops a classic syphilitic rash.
Journal Article > Study
Minimising human error in malaria rapid diagnosis: clarity of written instructions and health worker performance.
Rennie W, Phetsouvanh R, Lupisan S, et al. Trans R Soc Trop Med Hyg. 2006;101:9-18.
The authors describe the development of an instructional protocol to increase the reliability of rapid diagnostic testing of malaria.
Beck M. Wall Street Journal. September 14, 2014.
Overdiagnosis has emerged as a patient safety issue. Reporting on how the push for early identification of cancer has led to screening, detection, and treatment of tumors that may never cause harm, this newspaper article discusses the impact of unnecessary tests and treatment on patients and health systems. Researchers are working to design better tests to distinguish between benign abnormalities and cancers.
Boston, MA: Harvard School of Public Health; December 2014.
This statewide public telephone survey in Massachusetts found that more than 20% of respondents experienced a medical error in the prior 5 years, and more than half of these incidents resulted in harm. Prior patient surveys have brought to light previously unrecognized safety problems, although discrepancies have been shown to exist between patient reports and other methods for detecting adverse events. Most respondents attributed adverse events to individual physicians and nurses rather than health systems, underscoring the challenge of conveying blame-free culture and systems approaches to the public. Diagnostic errors were the most common type of error reported. About half of patients who experienced medical errors reported the incident to a clinician, hospital, or official agency. Most patients did not look for safety or quality information in choosing a physician or hospital, and only a third of respondents view patient safety as a serious problem for the state. Importantly, prior to being given an explanation, less than half of respondents understood the term "medical error." These findings emphasize the divide between the high prevalence of safety hazards and the lack of public awareness of patient safety efforts and policy.