American Association for Clinical Chemistry
Better health through laboratory medicine
Patient Safety Focus: Communication: Teaching Cases on the Web

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Communication: Teaching Cases on the Web
AHRQ’s Web Morbidity and Mortality Rounds

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Sponsored by the Agency for Healthcare Research and Quality and edited at the University of California, San Francisco, Morbidity and Mortality Rounds on the Web is a valuable resource that deserves more visibility among clinical laboratory professionals. The site contains a 5-year archive of actual cases submitted by healthcare providers, along with expert commentary and numerous references. Each case and commentary is a succinct, well-edited piece of about 1,500 words that supervisors could assign to lab staff or trainees as a continuing education activity. Many cases include laboratory medicine issues, but other cases are often applicable to the lab.

A large set of cases about communication issues can be accessed by typing “communication” into the Web site’s search field. Here is a synopsis of a few such cases that specifically involve problems in communicating lab test results.

Lost in Transition
Case ID #116
This case deals with a delay in receiving a critical platelet value that was due to a number of failures, including a handoff problem between caregivers in the emergency department and the hospital ward where the patient was admitted.

To LP or not LP
Case ID #34
In this case, communication failures between a physician and the patient’s family led to delays in performing lumbar puncture and associated laboratory testing. The delay in the diagnosis of meningitis placed the child at serious risk.

The Result Stopped Here
Case ID # 65
This case involves serious patient harm caused by failure to communicate a result that was actionable but not on the hospital’s critical value list. The commentary discusses some of the complexities surrounding creating adequate policies and procedures for reporting results. Like the “Lost in Transition” case, this case points out the implications of failing to follow-up on a laboratory test order.

Lost in the Black Hole
Case ID #31
This case describes problems in communicating an HIV PCR result that delayed diagnosis of acute HIV. It illustrates many of the communication gaps that arise as patients move between the inpatient and outpatient settings.


Patient Safety Focus Editorial Board

Chair
Michael Astion, MD, PhD
Department of Laboratory Medicine
University of Washington, Seattle

Members
Peggy A. Ahlin, BS, MT(ASCP)
ARUP Laboratories
Salt Lake City, Utah 
James S. Hernandez, MD, MS
Mayo Clinic College of Medicine
Rochester, Minn.
Devery Howerton, PhD
Centers for Disease Control and Prevention
Atlanta, Ga.

Sponsored by ARUP Laboratories, Inc.
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