PC142

Shipped August 2014

HISTORY

The challenge was sent to category A, B, C, and C1 laboratories. Participants were presented with the following scenario:

“Your laboratory has reported a joint fluid sam-ple isolate as coagulase-negative Staphylococcus species (CNS) for a patient and it turns out the isolate is later identified as yeast, rather than a CNS. How would you amend the original report?”

Please select the one option that best describes your lab’s protocol.

A. Substitute the amended report for the original report

B. Add the amended report to the original report and finalize

C. Add the amended report to the original report, finalize and phone the physician to inform him/her of the amendment

D. Cancel the culture and request recollection of the sample

E. Sample not applicable to or not normally processed by the laboratory

MAIN EDUCATIONAL POINTS from PC142

  1. Medical laboratory information consumers, including physicians, nurses and patients generally assume that the information on the written page is correct, and base their decisions and actions on that assumption.
  2. While one might argue that not all revisions to existing reports is an action associated with a medical laboratory error, the impact of not making revisions in a way to ensure that all people are aware to the new information would certainly be viewed as a reporting error.

Full critique (PDF)

Posted in Clinical Bacteriology Results, critiques