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 "United States of America"

1 - 20 of 144 results
Download Selected Citations

Show: 20 | 50 | 100

Journal Article > Study

Characteristics associated with requests by pathologists for second opinions on breast biopsies.

Geller BM, Nelson HD, Weaver DL, et al. J Clin Pathol. 2017 May 2; [Epub ahead of print].

Second opinions can shed light on challenging diagnoses. This observational cross-sectional study identified several clinical factors that prompted pathologists to seek second opinions for breast biopsies, including breast density, cellular atypia, and complex patients with multiple coexisting diagnoses. The authors suggest that such characteristics could prompt a second opinion in order to enhance diagnostic accuracy.

Journal Article > Study

Pathologists' perspectives on disclosing harmful pathology error.

Dintzis SM, Clennon EK, Prouty CD, Reich LM, Elmore JG, Gallagher TH. Arch Pathol Lab Med. 2017;141:841-845.

Disclosure of medical errors is a recommended patient safety practice. This focus group study of pathologists found that most pathologists believe treating clinicians should disclose pathology errors and express concern that treating clinicians do not understand the inherent limitations of pathologic diagnosis. The authors suggest that developing consensus guidelines may improve disclosure of pathology errors.

Journal Article > Study

Blood bank specimen mislabeling: a College of American Pathologists Q-Probes study of 41,333 blood bank specimens in 30 institutions.

Novis DA, Lindholm PF, Ramsey G, Alcorn KW, Souers RJ, Blond B. Arch Pathol Lab Med. 2017;141:255-259.

The rate of mislabeled blood samples in hospital laboratories did not improve significantly between 2007 and 2015, despite widespread implementation of barcoding and other safety methods during that time period. An error associated with a mislabeled blood sample is discussed in a past WebM&M commentary.

Journal Article > Study

Electronic detection of delayed test result follow-up in patients with hypothyroidism.

Meyer AND, Murphy DR, Al-Mutairi A, et al. J Gen Intern Med. 2017;32:753-759.

Trigger tools facilitate identification of adverse events. In this retrospective medical record review study, investigators found that an automated trigger successfully identified delayed follow-up of laboratory thyroid testing among patients with hypothyroidism, with a positive predictive value of 60%. The authors suggest that this trigger approach could be used to detect and ameliorate follow-up delays in real time.

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

Improving patient safety: avoiding unread imaging exams in the National VA enterprise electronic health record.

Bastawrous S, Carney B. J Digit Imaging. 2017;30:309-313.

Inadequate test result management is known to contribute to missed and delayed diagnosis. This Veterans Affairs study found that 0.17% of radiologic studies were not evaluated by radiologists. The study team identified several technical and process problems that contributed to these unread studies. They were able to address the issues to ensure all studies were read.

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 > Commentary

Towards a new paradigm in laboratory medicine: the five rights.

Plebani M. Clin Chem Lab Med. 2016;54:1881-1891.

Errors in the clinical laboratory testing process can lead to delays in diagnosis and treatment. Analytical mistakes and the harm they can cause are of particular concern. This commentary discusses the need to integrate key elements that enhance quality in each phase of the laboratory testing cycle to reduce opportunities for failure. The author advocates for improved engagement between clinicians and laboratory personnel to augment the reliability of the testing process.

Journal Article > Study

Opportunities to enhance laboratory professionals' role on the diagnostic team.

Taylor JR, Thompson PJ, Genzen JR, Hickner J, Marques MB. Lab Med. 2017;48:97-103.

Diagnostic error represents a significant source of patient harm. In this study, researchers surveyed physicians to understand how to improve the involvement of laboratory professionals in assisting with diagnostic challenges. They conclude that there may be a greater role for laboratory professionals in the diagnostic process beyond providing test results.

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 > Study

Surgical specimen management: a descriptive study of 648 adverse events and near misses.

Steelman VM, Williams TL, Szekendi MK, Halverson AL, Dintzis SM, Pavkovic S. Arch Pathol Lab Med. 2016;140:1390-1396.

Errors related to the handling of surgical specimens can lead to serious patient harm in the form of delayed and missed diagnoses as well as repeat procedures. In this retrospective review, researchers looked at 648 reported adverse events and near misses involving surgical specimen management. They found that all steps of the specimen handling process are subject to error, but specimen labeling, collection, and transport represented the most frequently reported incidents. Additionally, 52 of the events led to the need for further treatment or to patient harm. The authors suggest that to enhance the safety of specimen handling, organizations should develop standard processes, provide training for staff, improve communication and handoffs, and consider the use of technological systems that might facilitate tracking of specimens.

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 > Commentary

Improving pathologists' communication skills.

Dintzis S. AMA J Ethics. 2016;18:802-808.

Despite increasing recognition that effective communication supports teamwork and safe care delivery, opportunities for pathologists to improve their skill in this area are limited. This commentary describes a communication training initiative for pathology residents that involved lectures and simulation methods. Recordings of the simulated interactions allowed residents to perform self-assessment of communication skills such as error disclosure.

Journal Article > Commentary

Getting it right for patient safety: specimen collection process improvement from operating room to pathology.

D'Angelo R, Mejabi O. Am J Clin Pathol. 2016;146:8-17.

Mistakes in laboratory specimen labeling can contribute to diagnostic delay and error. This commentary describes an improvement initiative that enhanced teamwork between a pathology and surgical unit and applied Lean methodologies to redesign specimen labeling processes and reduce errors and inefficiencies over a 2-year period.

Journal Article > Study

Communicating findings of delayed diagnostic evaluation to primary care providers.

Meyer AND, Murphy DR, Singh H. J Am Board Fam Med. 2016;29:469-473.

Gaps in follow-up of abnormal test results are known to contribute to delays in diagnosis in primary care, yet primary care practices still lack standard processes to detect and manage abnormal test results. In this study, investigators identified specific abnormal test results requiring follow-up and tested an escalating strategy of communicating with primary care physicians about test results. The study team first sent a secure email with test results to providers, and if the appropriate diagnostic follow-up action did not occur within one week, they made up to three attempts to reach providers by telephone. Email spurred about 11% of providers to act, and more than two-thirds of providers followed up after receiving telephone calls. For the handful of providers who did not act in response to the email or telephone calls, investigators contacted clinic directors. However, even with this patient-specific communication intervention, follow-up of abnormal test results remained incomplete. These results demonstrate that communicating abnormal results to primary care providers is not sufficient to achieve optimal follow-up. As recommended in the Improving Diagnosis report, team-based results management or technological approaches may be needed to assist primary care providers in tracking and following up on outpatient results to promote timely and accurate diagnosis.

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 > 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.

Newspaper/Magazine Article

Bring back the autopsy.

Jauhar S. New York Times. March 3, 2016.

Performance of autopsies, previously considered an essential learning tool for clinicians, has decreased in recent years due to insufficient funding to cover costs and lack of physician endorsement of the practice. This newspaper article provides insights from a physician regarding how the decline in autopsies could affect care and highlights the benefits of autopsies in light of the current emphasis on improving diagnosis.

Back to Top