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Search results for "United States of America"

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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 > Commentary

Overdiagnosis of coronary artery disease detected by coronary computed tomography angiography: a teachable moment.

Schmidt T, Maag R, Foy AJ. JAMA Intern Med. 2016;176:1747-1748.

Overdiagnosis can result in financial, psychological, and physical harm to patients. This commentary discusses how a communication gap left a patient uninformed about the risks associated with an invasive cardiac procedure that was later found to be unnecessary.

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.

Newspaper/Magazine Article

Pathologists, patients and diagnostic errors—part 1 and part 2.

Miller N. The Pathologist. June 2016(20):18-29; July 2016(21):18-33.

In light of the growing focus on diagnostic errors, this magazine series reports on unique challenges that pathologists face when they discover potential errors. The first article in the series discusses how pathologists may experience barriers to disclosure including feeling shame in disclosing their own error, discomfort with raising concerns about a colleague who has misdiagnosed a patient, and lack of direct relationships with patients. The second article expands the discussion to focus on how industry support of open transparency can enable pathologists to participate in reporting and disclosure activities.

Newspaper/Magazine Article

An overreaction to food allergies.

Shell ER. Scientific American. October 20, 2015.

Reporting on how test inaccuracies can lead to misdiagnosis of food allergies in children and the potential consequences, this magazine article describes a diagnostic tool to detect allergies and a desensitization process to reduce incidence of allergies in children.

Newspaper/Magazine Article

Weak oversight allows lab failures to put patients at risk.

Gabler E. Milwaukee Journal Sentinel. May 15, 2015.

Reporting on weaknesses in laboratory testing methods, this news article discusses patients' experiences with testing errors to illustrate how such failures can contribute to patient harm—such as missed or delayed diagnosis—and raises concerns about insufficient transparency, investigations, and regulations around laboratory facilities with poor processes.

Special or Theme Issue

Pearls, Pitfalls, and Errors in Musculoskeletal Diagnosis.

Blankenbaker DG, ed. AJR Am J Roentgenol. 2014;203:476-593.

Articles in this special issue discuss common pitfalls in musculoskeletal imaging that can contribute to errors in trauma and extremity injury assessments, magnetic resonance imaging interpretation, and problems with ultrasound use.

Press Release/Announcement

Advocate Redi-Code+ blood glucose test strips by Diabetic Supply of Suncoast: recall—labeling error.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; June 11, 2014.

This announcement describes a recall of blood glucose test strips due to missing information on the label that could result in accidental misuse of test strips and potential delays in diagnosis and treatment of hyper- or hypoglycemia.

Journal Article > Commentary

The current and ideal state of anatomic pathology patient safety.

Raab SS. MLO Med Lab Obs. 2014;46:8-10.

This commentary illustrates the process of decision-making in pathology to reveal factors contributing to disagreements in interpretation of test results. Emphasizing how differences between slow thinking and fast thinking can cause interpretation errors, the author recommends system-level approaches and team-based solutions, respectively, to improve safety in pathology.

Journal Article > Study

Why pediatricians fail to diagnose hypertension: a multicenter survey.

Bijlsma MW, Blufpand HN, Kaspers GJ, Bökenkamp A. J Pediatr. 2014;164:173-177.e7.

In this observational study, investigators found that pediatricians often fail to measure blood pressure and misclassify elevated blood pressure as normal. These findings about this widespread diagnostic error are consistent with prior studies and emphasize the safety gap inherent in implementation of recommended practices.

Journal Article > Study

Decimal numbers and safe interpretation of clinical pathology results.

Sinnott M, Eley R, Steinle V, Boyde M, Trenning L, Dimeski G. J Clin Pathol. 2014;67:179-181.

According to this study, although most clinicians and medical laboratory staff reported having no difficulty with interpreting decimal numbers, many had trouble understanding pathology results. This finding underscores the need for clear and standardized reporting to ensure correct interpretation of test results.

Journal Article > Commentary

"Apologies" for pathologists: why, when, and how to say "sorry" after committing a medical error.

Dewar R, Parkash V, Forrow L, Truog R. Int J Surg Pathol. 2014;22:242-246.

This commentary explores how apologies and error disclosure are challenging for pathologists, due to their typical lack of direct contact with patients.

Journal Article > Commentary

"Just like EKGs!" Should EEGs undergo a confirmatory interpretation by a clinical neurophysiologist?

Benbadis SR. Neurology. 2013;80(suppl 1):S47-S51.

This commentary discusses how misinterpretation of electroencephalograms (EEGs) can lead to misdiagnosis of epilepsy and describes methods to prevent these incidents, such as mandatory EEG training during neurology residency.

Journal Article > Study

Inaccuracy of ECG interpretations reported to the poison center.

Prosser JM, Smith SW, Rhim ES, Olsen D, Nelson LS, Hoffman RS. Ann Emerg Med. 2011;57:122-127.

The emergency interpretation of electrocardiograms in poisoned patients was frequently incorrect, increasing the potential for diagnostic error and incorrect management.

Journal Article > Study

Accuracy of interpretation of preparticipation screening electrocardiograms.

Hill AC, Miyake CY, Grady S, Dubin AM. J Pediatr. 2011;159:783-788.

Controversy exists regarding whether children should be required to undergo an electrocardiogram before participating in competitive sports. This study found a significant rate of diagnostic error among pediatric cardiologists in the interpretation of abnormal screening electrocardiograms.

Newspaper/Magazine Article

Medical mystery: alcoholism didn’t cause man’s diabetes and cirrhosis.

Boodman SG. Washington Post. June 13, 2011:E1.

This newspaper article reveals how biases and lack of trust in the patient/family perspective may contribute to diagnostic error.

Newspaper/Magazine Article

Prone to error: earliest steps to find cancer.

Saul S. New York Times. July 19, 2010;A1.

This newspaper article investigates diagnostic errors in breast cancer through the story of a patient who was misdiagnosed. Concern about the accuracy of pathology for early stages of disease and ductal carcinoma in situ has experts debating the best mechanisms to ensure competency and reliability in this field.

Journal Article > Commentary

Responding to large-scale testing errors.

Valenstein PN, Alpern GA, Keren DF. Am J Clin Pathol. 2010;133:440-446.

Using two case examples, this article analyzes the causes and consequences of laboratory testing errors. The authors also identify responsibilities after such instances occur.

Audiovisual

Potentially fatal errors with GDH-PQQ [glucose dehydrogenase pyrroloquinoline quinone] glucose monitoring technology.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; August 13, 2009.

This public health notification raises awareness of the potential for falsely elevated blood glucose readings in patients using therapeutic products containing certain non-glucose sugars.

Journal Article > Study

Evaluation of the contributions of an electronic web-based reporting system: enabling action.

Levtzion-Korach O, Alcalai H, Orav EJ, et al. J Patient Saf. 2009;5:9-15.

The limitations of standard incident reporting systems have been well documented. Although ubiquitous and relatively easy to use, such systems detect only a fraction of adverse events, are underused by physicians, and yield data that often are not analyzed or disseminated promptly. This analysis of data from a commercial, web-based system at an academic hospital confirms some prior concerns, but the authors were able to demonstrate that rapid review of reports resulted in specific system changes to improve workflow and safety. A prior article presented a framework for using incident reporting data to improve patient safety.

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