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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.
Cases & Commentaries
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John Q. Young, MD, MPP; July 2011
A healthy elderly man presented to his primary care doctor—a third-year internal medicine resident—for routine examination. A PSA test was markedly elevated, but the results came back after the resident had graduated, and the alert went unread. Months later, the patient presented with new onset low back pain and was diagnosed with metastatic prostate cancer.