Narrow Results Clear All

Resource Type
Approach to Improving Safety
Safety Target
Setting of Care
Clinical Area
Target Audience
Error Types
Origin/Sponsor

Search results for "Health Care Executives and Administrators"

1 - 20 of 126 results
Download Selected Citations

Show: 20 | 50 | 100

Journal Article > Study

Hospital autopsy: endangered or extinct?

Turnbull A, Osborn M, Nicholas N. J Clin Pathol. 2015;68:601-604.

This study reports the declining autopsy rate in the United Kingdom, consistent with practice in the United States. The authors raise concerns, expressed in prior studies, about the lost information, particularly around diagnosis, from fewer autopsies.

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.

Press Release/Announcement

Implantable infusion pumps in the magnetic resonance (MR) environment: FDA safety communication—important safety precautions.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; January 11, 2017.

Hazards in the magnetic resonance imaging environment can result in patient harm. This announcement raises awareness of inaccuracies and disruptions that may affect the safety of patients with implantable infusion devices who undergo an MRI exam. The statement recommends that patients inform their care team and carry an implant card with information about the implanted device to prevent these problems.

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

Significant reduction in preanalytical errors for nonphlebotomy blood draws after implementation of a novel integrated specimen collection module.

Le RD, Melanson SE, Petrides AK, et al. Am J Clin Pathol. 2016;146:456-461.

Laboratory errors, such as mislabeling, improper collection, or specimen loss, can lead to delays in diagnosis and the need for repeat procedures or blood draws. In this single institution study, implementing a custom-built specimen collection module led to a significant decrease in the rate of lab specimen collection and handling errors for blood samples drawn by nurses in both the emergency department and inpatient settings.

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 > 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 > Commentary

Patient identification and tube labelling—a call for harmonisation.

van Dongen-Lases EC, Cornes MP, Grankvist K, et al; Working Group for Preanalytical Phase (WG-PRE), European Federation of Clinical Chemistry and Laboratory Medicine (EFLM). Clin Chem Lab Med. 2016;54:1141-1145.

Specimen labeling errors can result in patient misidentification and harm. This position paper draws from international guidelines to advocate for standardizing the processes involved in phlebotomy to reduce the potential for both patient and sample labeling errors. The authors recommend strategies for improvement including barcoding, staff training, and monitoring of mistakes to inform process enhancements.

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 > Study

Patient safety in genomic medicine: an exploratory study.

Korngiebel DM, Fullerton SM, Burke W. Genet Med. 2016;18:1136-1142.

This qualitative study of patient safety risks in genetic testing uncovered potential for adverse events at all stages of testing. Both technology limitations and lack of physician knowledge emerged as significant concerns. These results demonstrate the need for systematic interventions to enhance the safety of genetic testing.

Audiovisual

Scalia's death and the value of autopsy: a teachable moment.

Lundberg GD. Medscape. March 21, 2016.

Although autopsies were previously considered an essential learning tool, their use has dramatically declined over time. Following a recent unexpected death of a high-profile individual, the author elucidates the instructive benefits of performing autopsies from determining cause of death to identifying diagnostic errors.

Journal Article > Study

Identifying risk in the use of tumor markers to improve patient safety.

Moreno-Campoy EE, Mérida-De la Torre FJ, Martos-Crespo F, Plebani M. Clin Chem Lab Med. 2016;54:1947-1953.

Inappropriate use of laboratory tests can contribute to missed and delayed diagnosis. This retrospective chart review found that the majority of tumor marker tests requested in an academic hospital were incompletely or inaccurately ordered when compared to current guidelines. These results suggest that enhancing test ordering is critical for improving diagnostic safety.

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.

Journal Article > Commentary

Interpretive diagnostic error reduction in surgical pathology and cytology: guideline from the College of American Pathologists Pathology and Laboratory Quality Center and the Association of Directors of Anatomic and Surgical Pathology.

Nakhleh RE, Nosé V, Colasacco C, et al. Arch Pathol Lab Med. 2016;140:29-40.

Misinterpretation of test results can have harmful consequences for patients. This guideline synthesized the literature on surgical pathology and cytology case reviews to determine recommendations to improve diagnostic accuracy, such as involving anatomic pathologists in developing procedures to detect disagreements and errors, conducting case reviews in a timely fashion, and continuously tracking and documenting case review findings.

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

Diagnostic concordance among pathologists interpreting breast biopsy specimens.

  • Classic

Elmore JG, Longton GM, Carney PA, et al. JAMA. 2015;313:1122-1132.

Microscopic review of biopsy tissue is considered the gold standard for diagnosis of cancer and other diseases, but prior research has shown a small yet consistent rate of errors in cancer diagnosis that is attributable to misinterpretation of biopsy specimens. This study sought to quantify error rates in breast cancer diagnosis by having a broad sample of pathologists review a standardized set of biopsies whose diagnoses had been established by expert clinicians. Although biopsies with cancer were diagnosed very accurately, specimens with atypia (abnormal tissue that may be pre-cancerous) had substantial variability, with pathologists tending to overdiagnose these specimens (i.e., ascribe a diagnosis of cancer or pre-cancerous lesions when the correct diagnosis was benign). The authors caution that the specimens used in this study were intentionally chosen to be relatively difficult to interpret, and this may have resulted in overestimating the error rate. A related editorial notes that while the overall rate of diagnostic error in this study was low, misdiagnosis of atypia does have important prognostic and treatment significance for women, and therefore pathologists should systematically consult with colleagues in difficult cases, and more advanced molecular diagnostic methods should be applied in order to reduce subjectivity in biopsy interpretation.

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.

Journal Article > Study

Laboratory medicine handoff gaps experienced by primary care practices: a report from the Shared Networks of Collaborative Ambulatory Practices and Partners (SNOCAP).

West DR, James KA, Fernald DH, Zelie C, Smith ML, Raab SS. J Am Board Fam Med. 2014;27:796-803.

This survey-based study of primary care providers revealed a lack of standardization for the tracking, receiving, and reporting of laboratory results. Even practices with integrated electronic medical records reported the need for a back-up tracking system to ensure important test results are not lost.

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.

Back to Top