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Search results for "Diagnostic Test Interpretation Error"
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James L. Rudolph, MD, SM; May 2009
An elderly woman hospitalized for pneumonia becomes disoriented during hospitalization. Even though the patient was never confused at baseline, doctors attribute it to "senile dementia" and place her in restraints.
Journal Article > Study
Levtzion-Korach O, Alcalai H, Orav EJ, et al. J Patient Saf. 2009;5:9-15.
The limitations of standard incident reporting systems have been well documented. Although ubiquitous and relatively easy to use, such systems detect only a fraction of adverse events, are underused by physicians, and yield data that often are not analyzed or disseminated promptly. This analysis of data from a commercial, web-based system at an academic hospital confirms some prior concerns, but the authors were able to demonstrate that rapid review of reports resulted in specific system changes to improve workflow and safety. A prior article presented a framework for using incident reporting data to improve patient safety.