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Search results for "Active Errors"

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Cases & Commentaries

Delayed Recognition of a Positive Blood Culture

  • Web M&M

Sarah Doernberg, MD, MAS; July 2017

A woman was discharged with instructions to complete an antibiotic course for C. difficile. The same day, the microbiology laboratory notified the patient's nurse that her blood culture grew Listeria monocytogenes, a bacterium that can cause life-threatening infection. However, the result was not communicated to the medical team prior to discharge.

Cases & Commentaries

Hemolysis Holdup

  • Web M&M

Christopher M. Lehman, MD; May 2017

In the emergency department, an older man with multiple medical conditions was found to have evidence of acute kidney injury and an elevated serum potassium level. However, the blood sample was hemolyzed, which can alter the reading. Although the patient was admitted and a repeat potassium level was ordered, the physician did not institute treatment for hyperkalemia. Almost immediately after the laboratory called with a panic result indicating a dangerously high potassium level, the patient went into cardiac arrest.

Journal Article > Study

Pathologists' perspectives on disclosing harmful pathology error.

Dintzis SM, Clennon EK, Prouty CD, Reich LM, Elmore JG, Gallagher TH. Arch Pathol Lab Med. 2017;141:841-845.

Disclosure of medical errors is a recommended patient safety practice. This focus group study of pathologists found that most pathologists believe treating clinicians should disclose pathology errors and express concern that treating clinicians do not understand the inherent limitations of pathologic diagnosis. The authors suggest that developing consensus guidelines may improve disclosure of pathology errors.

Journal Article > Review

Managing the patient identification crisis in healthcare and laboratory medicine.

Lippi G, Mattiuzzi C, Bovo C, Favaloro EJ. Clin Biochem. 2017;50:562-567.

Patient identification mistakes associated with diagnostic blood testing can have serious consequences. This commentary recommends several strategies to redesign laboratory processes to reduce risks of specimen misidentification, such as utilizing at least two patient identifiers, providing staff training, and using technologies to track and manage specimens.

Journal Article > Study

Blood bank specimen mislabeling: a College of American Pathologists Q-Probes study of 41,333 blood bank specimens in 30 institutions.

Novis DA, Lindholm PF, Ramsey G, Alcorn KW, Souers RJ, Blond B. Arch Pathol Lab Med. 2017;141:255-259.

The rate of mislabeled blood samples in hospital laboratories did not improve significantly between 2007 and 2015, despite widespread implementation of barcoding and other safety methods during that time period. An error associated with a mislabeled blood sample is discussed in a past WebM&M commentary.

Cases & Commentaries

Safeguarding Diagnostic Testing at the Point of Care

  • Web M&M

Gerald J. Kost, MD, PhD, MS, and Sharon Ehrmeyer, PhD; February 2017

In an outpatient clinic, the nurse entered results of all daily point-of-care tests into the electronic health record at the end of her shift. She mistakenly entered one patient's urine pregnancy test result as positive instead of negative. When the patient's provider received electronic notification of the result, she recognized the error and corrected the medical record.

Journal Article > Study

Electronic detection of delayed test result follow-up in patients with hypothyroidism.

Meyer AND, Murphy DR, Al-Mutairi A, et al. J Gen Intern Med. 2017;32:753-759.

Trigger tools facilitate identification of adverse events. In this retrospective medical record review study, investigators found that an automated trigger successfully identified delayed follow-up of laboratory thyroid testing among patients with hypothyroidism, with a positive predictive value of 60%. The authors suggest that this trigger approach could be used to detect and ameliorate follow-up delays in real time.

Journal Article > Study

Improving patient safety: avoiding unread imaging exams in the National VA enterprise electronic health record.

Bastawrous S, Carney B. J Digit Imaging. 2017;30:309-313.

Inadequate test result management is known to contribute to missed and delayed diagnosis. This Veterans Affairs study found that 0.17% of radiologic studies were not evaluated by radiologists. The study team identified several technical and process problems that contributed to these unread studies. They were able to address the issues to ensure all studies were read.

Cases & Commentaries

The Missing Abscess: Radiology Reads in the Digital Era

  • Spotlight Case
  • CME/CEU
  • Web M&M

Eliot L. Siegel, MD; January 2017

Following a hysterectomy, a woman was discharged but then readmitted for pelvic pain. The radiologist reported a large pelvic abscess on the repeat CT scan, and the gynecologist took the patient to the operating room for treatment based on the report alone, without viewing the images herself. In the OR, the gynecologist could not locate the abscess and stopped the surgery to look at the CT images. She realized that what the radiologist had read as an abscess was the patient's normal ovary.

Journal Article > Study

Breast cancer screening in Denmark: a cohort study of tumor size and overdiagnosis.

  • Classic

Jørgensen KJ, Gøtzsche PC, Kalager M, Zahl P. Ann Intern Med. 2017;166:313-323.

The overuse of medical care is increasingly recognized as a patient safety issue. Overdiagnosis can result in unnecessary use of medical care, subjecting patients to greater risk of harm. For example, in the case of breast cancer, screening may detect lesions that are not clinically significant, leading to further testing and unnecessary procedures. This study examined the impact of mammography screening on a cohort of women in Denmark. Researchers found that screening was not associated with decreased incidence of advanced cancer but increased incidence of nonadvanced tumors and ductal carcinoma in situ; the rate of overdiagnosis was significant. An accompanying editorial discusses overdiagnosis in breast cancer.

Journal Article > Study

Discrepancies between clinical diagnoses and autopsy findings in critically ill children: a prospective study.

Carlotti AP, Bachette LG, Carmona F, Manso PH, Vicente WV, Ramalho FS. Am J Clin Pathol. 2016;146:701-708.

This autopsy study demonstrated significant discrepancies between clinical and postmortem diagnoses among children who died in the intensive care unit. These results demonstrate the importance of autopsy as an educational tool for clinical teams to improve patient outcomes.

Journal Article > Study

Strategies for improving the value of the radiology report: a retrospective analysis of errors in formally over-read studies.

Kabadi SJ, Krishnaraj A. J Am Coll Radiol. 2017;14:459-466.

This retrospective review of imaging studies submitted to a second institution for a second interpretation (over-read) revealed that more than 10% had clinically significant changes between the original interpretation and the second interpretation. Nearly one-quarter of the changes were classified as emergent, requiring immediate notification to a treating clinician. These results demonstrate how imaging interpretation can affect timely and accurate diagnosis.

Journal Article > Study

Opportunities to enhance laboratory professionals' role on the diagnostic team.

Taylor JR, Thompson PJ, Genzen JR, Hickner J, Marques MB. Lab Med. 2017;48:97-103.

Diagnostic error represents a significant source of patient harm. In this study, researchers surveyed physicians to understand how to improve the involvement of laboratory professionals in assisting with diagnostic challenges. They conclude that there may be a greater role for laboratory professionals in the diagnostic process beyond providing test results.

Journal Article > Review

Error disclosure in pathology and laboratory medicine: a review of the literature.

Perkins IU. AMA J Ethics. 2016;18:809-816.

Disclosure of errors to patients and families contributes to transparency in health care. This review explores barriers to disclosing diagnostic errors to patients in pathology and laboratory medicine and makes recommendations to address these challenges.

Journal Article > Commentary

Getting it right for patient safety: specimen collection process improvement from operating room to pathology.

D'Angelo R, Mejabi O. Am J Clin Pathol. 2016;146:8-17.

Mistakes in laboratory specimen labeling can contribute to diagnostic delay and error. This commentary describes an improvement initiative that enhanced teamwork between a pathology and surgical unit and applied Lean methodologies to redesign specimen labeling processes and reduce errors and inefficiencies over a 2-year period.

Journal Article > Study

Evaluation of 12 strategies for obtaining second opinions to improve interpretation of breast histopathology: simulation study.

Elmore JG, Tosteson AN, Pepe MS, et al. BMJ. 2016;353:i3069.

This study found that eliciting second opinions in pathology improved the accuracy of breast histopathology specimens. This work provides further evidence that diagnostic accuracy can be enhanced with second opinions. The authors suggest that implementing multiple clinician review may augment the diagnostic process.

Journal Article > Study

Computerized triggers of big data to detect delays in follow-up of chest imaging results.

Murphy DR, Meyer AND, Bhise V, et al. Chest. 2016;150:613-620.

Insufficient follow-up of test results is a known contributor to missed and delayed diagnosis. This observational study used a trigger tool to detect diagnostic delays related to chest imaging follow-up. Investigators used an automated algorithm to identify chest imaging cases that potentially had a follow-up delay. A clinician then reviewed the medical records for a random sample of cases identified by the trigger tool and a reference set of cases involving patients with abnormal test results but no delays. They found that the trigger tool had 99% sensitivity and 38% specificity in detecting delays in follow-up of abnormal chest imaging. The authors suggest that this trigger tool may help identify patients at risk for diagnostic delay following abnormal chest imaging. A WebM&M commentary discussed delayed follow-up of a diagnostic test.

Newspaper/Magazine Article

An overreaction to food allergies.

Shell ER. Scientific American. October 20, 2015.

Reporting on how test inaccuracies can lead to misdiagnosis of food allergies in children and the potential consequences, this magazine article describes a diagnostic tool to detect allergies and a desensitization process to reduce incidence of allergies in children.

Journal Article > Study

Data quality associated with handwritten laboratory test requests: classification and frequency of data-entry errors for outpatient serology tests.

Vecellio E, Maley MW, Toouli G, Georgiou A, Westbrook J. HIM J. 2015;44:7-12.

This audit of handwritten laboratory orders transcribed into electronic information systems found a 10% error rate, most of which were associated with transcription, a known safety vulnerability. These results underscore the benefit of computerized physician order entry for patient safety.

Journal Article > Review

How well do health professionals interpret diagnostic information? A systematic review.

Whiting PF, Davenport C, Jameson C, et al. BMJ Open. 2015;5:e008155

This review of the evidence on test interpretation found that, across multiple studies, clinicians do not accurately interpret common measures of test accuracy such as likelihood ratios. This suggests a role for decision support in this area which could better inform clinicians' test result interpretation.

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