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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

Correct Treatment Plan for Incorrect Diagnosis: A Pharmacist Intervention

  • Web M&M

Scott D. Nelson, PharmD, MS; March 2017

Although meningitis and neurosyphilis were ruled out for a woman presenting with a headache and blurry vision, blood tests returned indicating latent (inactive) syphilis. Due to a history of penicillin allergy, the patient was sent for testing for penicillin sensitivity, which was negative. The allergist placed orders for neurosyphilis treatment—a far higher penicillin dose than needed to treat latent syphilis, and a treatment regimen that would have required hospitalization. Upon review, the pharmacist saw that neurosyphilis had been ruled out, contacted the allergist, and the treatment plan was corrected.

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.

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.

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

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.

Journal Article > Commentary

A piece of my mind. Writing the wrong.

Patel JJ. JAMA. 2015;314:671-672.

Despite the potential for electronic health record (EHR) systems to improve access to patient data, unintended consequences have emerged that can hinder information seeking. To highlight how EHRs can detract from patient–physician relationships, this commentary reveals insights from a physician who failed to notice a patient's respiratory failure and distress due to over-reliance on the EHR.

Newspaper/Magazine Article

Weak oversight allows lab failures to put patients at risk.

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.

Journal Article > Study

Development and validation of electronic health record–based triggers to detect delays in follow-up of abnormal lung imaging findings.

Murphy DR, Thomas EJ, Meyer AND, Singh H. Radiology. 2015;277:81-87.

Delays in follow-up of abnormal test results are known to contribute to delayed and missed diagnosis. Investigators developed and validated an electronic trigger to identify potential delays in follow-up of abnormal chest computed tomography scans. This study found that more than half of the flagged cases had a true diagnostic delay. This work should lead to prospective evaluation of trigger approaches to enhance test result follow-up.

Journal Article > Study

Linking acknowledgement to action: closing the loop on non-urgent, clinically significant test results in the electronic health record.

Dalal AK, Pesterev BM, Eibensteiner K, Newmark LP, Samal L, Rothschild JM. J Am Med Inform Assoc. 2015;22:905-908.

Failure to follow-up on test results in ambulatory practice is a common, serious safety concern. This study examined the use of a results manager tool by primary care physicians in Partners Healthcare in Boston. Although the vast majority of providers used the tool, many did not find that it was helpful for any specific purpose and only 64% were satisfied with the tool.

Cases & Commentaries

Critical Opportunity Lost

  • Web M&M

Jonathan R. Genzen, MD, PhD, and Heather N. Signorelli, DO; March 2015

After presenting to the emergency department, a woman with chest pain was given nitroglycerine and a so-called GI cocktail. Her electrocardiogram was unremarkable, and she was scheduled for a stress test the next morning. A few minutes into the stress test, the patient collapsed and went into cardiac arrest.

Newspaper/Magazine Article

The high cost of low morale in the clinical laboratory: how workplace environment impacts patient safety.

Barker T, Noguez J. Clinical Laboratory News. January 1, 2015.

Reporting on the importance of a supportive workplace environment that engages employees in tasks to help ensure safety, this news article discusses root causes for low staff morale in the laboratory environment and suggests tactics to build healthy staff relationships.

Audiovisual > Audiovisual Presentation

Patient Safety Essentials for Laboratory Professionals Certificate Program.

Washington, DC: American Association for Clinical Chemistry.

This certificate program for laboratory professionals offers six courses aimed at enhancing participants' skills in establishing a just culture, identifying safety hazards, and assessing gaps in processes to reduce risks of specimen management errors.

Journal Article > Study

Are amended surgical pathology reports getting to the correct responsible care provider?

Parkash V, Domfeh A, Cohen P, et al. Am J Clin Pathol. 2014;142:58-63.

In this chart review study, amended pathology reports with clinically significant patient results did not reliably reach treating clinicians. Despite prior studies highlighting the shortcomings of test results reporting, this patient safety issue persists.

Newspaper/Magazine Article

Managing risk at the point-of-care: preventing errors.

Njoroge S, Nichols JH. Clinical Laboratory News. July 2014.

Highlighting how the disconnect between clinicians conducting point-of-care testing as a patient care action and laboratory staff performing the analysis of the test can affect detection of errors, this news article suggests quality control strategies to address risks related to monitoring, testing, and device use.

Journal Article > Study

A multidisciplinary, multifaceted improvement initiative to eliminate mislabelled laboratory specimens at a large tertiary care hospital.

Seferian EG, Jamal S, Clark K, et al. BMJ Qual Saf. 2014;23:690-697.

This quality improvement initiative used human factors approaches including failure mode and effect analysis, event review, and root cause analysis to successfully reduce the rate of specimen mislabeling in an inpatient setting. This study highlights the importance of re-examining longstanding work processes to augment safety.

Journal Article > Commentary

Patient safety and quality care.

Nelson K. Clin Dermatol. 2014;32:542-544.

This commentary reveals insights from a physician who was involved in a misidentified specimen incident. The author explains how the organization performed a root cause analysis to determine safety gaps in specimen handling processes and recommends four key steps to prevent errors.

Book/Report

Healthcare Inspection—Emergency Department Patient Deaths: Memphis VAMC, Memphis, Tennessee.

Washington, DC: Department of Veterans Affairs, Office of Inspector General; October 23, 2013. Report No. 13-00505-348.

This investigation into three patients who died in an emergency department uncovered problems related to medication ordering, alert response, and test result tracking.

Journal Article > Study

An initiative to improve the management of clinically significant test results in a large health care network.

Roy CL, Rothschild JM, Dighe AS, et al. Jt Comm J Qual Patient Saf. 2013;39:517-527.

Appropriate follow-up of abnormal test results remains a difficult issue. This local task force report recommends standardization of notification policies, clear identification of the care team, enhanced electronic result tracking, and quality reporting and metrics.

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