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Appendix D: Examples of Diagnostic Error
Pages 437-444

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From page 437...
... Consistent with the earlier IOM report, this report on diagnostic error in health care also emphasizes the need to look at errors in the diagnostic process, which is embedded in a larger work system. The case studies presented in this appendix provide snapshots of various diagnostic errors.
From page 438...
... A misread X-ray of patient with pneumonia led to respiratory failure and death A 55-year-old male was diagnosed by his primary care clinician with sinusitis and prescribed an antibiotic. Six days later, he was evaluated in an urgent care clinic for shortness of breath, labored breathing, extreme fatigue, and chest pain with cough.
From page 439...
... His daughter, who cares for him, states that his endocrinologist had ordered laboratory tests the prior month, so she thought he did not need any more blood drawn. He reports feeling generally weak and unwell, so his primary care physician orders laboratory tests done the same day, and he is found to have dangerously low serum sodium.
From page 440...
... Ultrasonography shows no free fluid in the chest; a chest film appears normal, with no pneumothorax; and an abdominal series is normal, with no free air. There is considerable discussion between the resident and the attending physician regarding the management of posterior chest stab wounds, but eventually agreement is reached that computed tomography (CT)
From page 441...
... Rushed communication leads to error The doctor informs the patient to refrain from aspirin ingestion prior to a partic ular laboratory test involving platelets. The consultation with the patient is rushed, and the physician fails to explain to the patient that aspirin is present in many medicines and that the patient should determine whether any over-the-counter product contains aspirin prior to using it.
From page 442...
... Laposata, 2010; permission conveyed through Copyright Clearance Center. Poor emergency department diagnostic test tracking and reporting A young woman with a complicated medical history, including systemic lupus erythematosis (lupus)
From page 443...
... Through genomic analy sis conducted in subsequent months, NIH doctors ultimately discovered that muta tions in Aurelius' DNA caused loss in the function of an enzyme called CYP24A1, which results in high vitamin D levels. With his wife's help, Aurelius made dietary changes that have brought about vast improvements in his condition)
From page 444...
... 2009. Refocusing the lens: Patient safety in ambulatory chronic disease care.


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