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Search results for "Hospitals"

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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.

Journal Article > Study

Reduction in hospital-wide clinical laboratory specimen identification errors following process interventions: a 10-year retrospective observational study.

Ning HC, Lin CN, Chiu DTY, et al. PLoS One. 2016;11:e0160821.

Correct identification of patient specimens is crucial to timely and accurate diagnosis. This pre–post study demonstrated substantial improvements in already low rates of patient specimen identification errors following each of three successive strategies: discarding improperly labeled specimens, using barcodes, and automating specimen labeling.

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.

Book/Report

Meeting the Joint Commission's 2013 National Patient Safety Goals.

Oakbrook Terrace, IL: The Joint Commission; September 2012. ISBN: 9781599407555.

This e-book provides tips for incorporating activities into daily hospital practice in conjunction with the 2013 National Patient Safety Goals.

Cases & Commentaries

Amended Lab Results: Communication Slip

  • Web M&M

Vanitha Janakiraman Mohta, MD; February 2012

A pregnant woman with new onset hypertension and proteinuria was admitted to the hospital for further testing. Test results for a 24-hour urine collection were initially reported as normal in the electronic medical record, and discharge planning was begun. However, a later amended report showed the results were elevated and abnormal, confirming a diagnosis of preeclampsia.

Journal Article > Study

Improving the discharge process by embedding a discharge facilitator in a resident team.

Finn KM, Heffner R, Chang Y, et al. J Hosp Med. 2011;6:494-500.

The disturbingly high incidence of readmissions after hospital discharge remains a national policy priority, as many readmissions can be linked to adverse events after discharge. In this study, a nurse practitioner (NP) was assigned to a resident inpatient medical team at a tertiary care hospital, with the specific responsibility of facilitating the discharge process. The NP's responsibilities included arranging follow-up appointments, performing medication reconciliation, and following up on tests pending at discharge. Although NP discharge facilitation achieved improved patient satisfaction with the discharge process, higher rates of timely outpatient follow-up, and improved resident work efficiency, it did not result in fewer readmissions or emergency department visits in the post-discharge period. The complex nature of preventing readmissions is discussed in an AHRQ WebM&M interview with Dr. Eric Coleman.

Journal Article > Study

Association of ICU or hospital admission with unintentional discontinuation of medications for chronic diseases.

  • Classic

Bell CM, Brener SS, Gunraj N, et al. JAMA. 2011;306:840-847.

Care transitions are a vulnerable time for patients, particularly following hospitalization when discharge communication, pending tests, and medication reconciliation are all known challenges. This study analyzed a population-based data set containing both hospitalization and outpatient prescription records to identify the incidence of potentially unintentional medication discontinuation among patients 66 years or older. Analyzing nearly 400,000 patients, investigators found high rates of medication discontinuation ranging from 5% to 19% across 5 evidence-based medication classes (e.g., lipid lowering, thyroid replacement, antiplatelet agents) for hospitalized patients. Admission to the ICU was associated with an even greater risk of medication discontinuation. While some medication discontinuation is not surprising in the setting of a critical illness that may create new contraindications to preexisting medications, both this study and an accompanying editorial [see link below] raise appropriate concern about carefully reconciling chronic disease medications following hospitalization. A past AHRQ WebM&M conversation and perspective discussed the challenges and opportunities for improving care transitions.

Newspaper/Magazine Article

Entire UPMC transplant team missed hepatitis alert.

Hamill SD. Pittsburgh Post-Gazette. July 10, 2011:A6.

This newspaper article reports how a missed test result alert led to a disease-free transplant patient being infected with hepatitis.

Journal Article > Study

Real-time automated paging and decision support for critical laboratory abnormalities.

Etchells E, Adhikari NK, Wu R, et al. BMJ Qual Saf. 2011;20:924-930.

In this study, clinicians were notified in real time about critical lab test abnormalities and provided with immediate decision support. However, this intervention did not prevent adverse events attributable to the critical test results, nor did it seem to result in more timely management.

Newspaper/Magazine Article

Medical misdiagnoses can have fatal consequences.

Olsen D. State Journal-Register. June 26, 2011.

This newspaper article discusses a case of diagnostic error, explores the complexity of the diagnostic process, and provides tips to help patients avoid such errors.

Journal Article > Commentary

Ten years after the IOM report: engaging residents in quality and patient safety by creating a house staff quality council.

Fleischut PM, Evans AS, Nugent WC, et al. Am J Med Qual. 2011;26:89-94.

This commentary describes one hospital's approach to engage residents in improving patient safety.

Cases & Commentaries

Failure to Reevaluate

  • Web M&M

Annie Wong-Beringer, PharmD; December 2010

A patient on palliative chemotherapy was given intravenous vancomycin for methicillin-resistant staphylococcus aureus (MRSA), despite a rising creatinine level, and went into acute kidney failure.

Journal Article > Study

Lessons learned from implementation of a computerized application for pending tests at hospital discharge.

Dalal AK, Poon EG, Karson AS, Gandhi TK, Roy CL. J Hosp Med. 2011;6:16-21.

Describing the experience of one hospital's implementation of an electronic system to help track and manage tests pending at hospital discharge, this study describes the surprisingly large number of barriers to developing safe and effective systems to deal with such tests at discharge.

Cases & Commentaries

Treatment Challenges After Discharge

  • Spotlight Case
  • Web M&M

Chase Coffey, MD, MS; November 2010

A man returns to the emergency department 11 days after hospital discharge in worsening condition. With no follow-up on a urine culture and sensitivity sent during his hospitalization, the patient had been taking the wrong antibiotic for a UTI.

Newspaper/Magazine Article

Diagnostic error in acute care.

PA-PSRS Patient Saf Advis. 2010;7:76-86.  

Analyzing reports of diagnostic errors, this article discusses common causes and provides suggestions for physicians and patients to prevent such events.

Journal Article > Study

Errors of diagnosis in pediatric practice: a multisite survey.

Singh H, Thomas EJ, Wilson L, et al. Pediatrics. 2010;126:70-79.

A considerable number of patients suffer preventable harm due to diagnostic errors every year. Our knowledge of underlying causes of missed diagnoses, and the types of diagnoses that are often missed, are largely based on autopsy studies and data from malpractice claims, which may over-represent diagnoses that cause death or serious disability. The 1300 pediatricians and pediatric trainees surveyed in this study identified misdiagnosis of viral illnesses as bacterial infections and failure to recognize medication side effects as the most common types of diagnostic error. Faulty information gathering and suboptimal communication were named as the principal individual and system factors leading to diagnostic error. Physicians named closer follow-up and reliable test management systems as major system improvements that could reduce the risk of diagnostic error.

Journal Article > Study

Decreasing mislabeled laboratory specimens using barcode technology and bedside printers.

Brown JE, Smith N, Sherfy BR. J Nurs Care Qual. 2011;26:13-21.

This study found a significant reduction in mislabeled blood specimens after implementing barcode technology.

Journal Article > Commentary

Eight recommendations for policies for communicating abnormal test results.

Singh H, Vij MS. Jt Comm J Qual Patient Saf. 2010;36:226-232.

This article details specific principles for developing organizational policies to improve test-result communication.

Journal Article > Study

Real-time clinical alerting: effect of an automated paging system on response time to critical laboratory values—a randomised controlled trial.

Etchells E, Adhikari NKJ, Cheung C, et al. Qual Saf Health Care. 2010;19:99-102.

Reporting critical laboratory results directly to physicians' pagers resulted in more rapid corrective action compared with reporting abnormal results by phone to the hospital ward.

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