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ISMP Medication Safety Alert! Acute Care Edition. March 8, 2012;17:1-3.
This newsletter piece discusses the pros and cons of physicians dispensing medications and its impact on patient safety.
Journal Article > Study
Aaronson EL, Quinn GR, Wong CI, et al. J Healthc Risk Manag. 2019 Jul 23; [Epub ahead of print].
Malpractice risk in the outpatient setting is significant and claims often involve missed and delayed diagnoses. This retrospective study examined diagnostic error claims in outpatient general medicine to identify characteristics and causes of cancer misdiagnoses. Similar to a prior study, investigators found that missed cancer diagnosis is the leading type of diagnostic error in primary care, constituting nearly half of closed diagnostic claims. Contributing factors included failure or delay in test ordering or consultation. These findings suggest that improving test results management and consultative processes may reduce malpractice risk related to outpatient diagnosis. A previous WebM&M commentary discussed an incident involving a missed diagnosis of spinal cord injury in primary care.
Journal Article > Commentary
Chemotherapy in home care: one team's performance improvement journey toward reducing medication errors.
Ewen BM, Combs R, Popelas C, Faraone GM. Home Healthc Nurse. 2012;30:28-37.
This commentary describes how a medication administration error launched one organization's efforts to improve patient safety statewide.
Cases & Commentaries
- Spotlight Case
- Web M&M
Eric S. Holmboe, MD; February 2011
A man diagnosed with chronic hepatitis C was treated with interferon and ribavirin by his internist without referral for a liver biopsy or the appropriate blood tests. Treatment was continued for months despite the patient developing pancytopenia and continuing to have a high viral load, raising questions about physicians practicing outside their areas of competency.