Document Detail

Are amended surgical pathology reports getting to the correct responsible care provider?
MedLine Citation:
PMID:  24926086     Owner:  NLM     Status:  In-Data-Review    
OBJECTIVES: Amended reports (AmRs) need to follow patients to treating physicians, to avoid erroneous management based on the original diagnosis. This study was undertaken to determine if AmRs followed the patient appropriately.
METHODS: AmRs with diagnostic changes and discrepancies between ordering and treating physicians were tracked. Chart reviews, electronic medical report (EMR) reviews, and interviews were conducted to establish receipt of the AmR by the correct physician.
RESULTS: Seven of 60 AmRs had discrepancies between the ordering and treating physicians, all with malignant diagnoses. The AmR was present in the treating physician's chart in only one case. Ordering physicians indicated that AmRs were not forwarded to treating physicians when corrected results arrived after patient referral, under the assumption that the new physician was automatically forwarded pathology updates. No harm was documented in any of our cases. In one case with a significant amendment, the correct information was entered in the patient chart based on a tumor board discussion. A review of two electronic health record systems uncovered significant shortcomings in each delivery system.
CONCLUSIONS: AmRs fail to follow the patient's chain of referrals to the correct care provider, and EMR systems lack the functionality to address this failure and alert clinical teams of amendments.
Vinita Parkash; Akosua Domfeh; Paul Cohen; Neal Fischbach; Mary Pronovost; G Kenneth Haines; Peter Gershkovich
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Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  American journal of clinical pathology     Volume:  142     ISSN:  1943-7722     ISO Abbreviation:  Am. J. Clin. Pathol.     Publication Date:  2014 Jul 
Date Detail:
Created Date:  2014-06-13     Completed Date:  -     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  0370470     Medline TA:  Am J Clin Pathol     Country:  United States    
Other Details:
Languages:  eng     Pagination:  58-63     Citation Subset:  AIM; IM    
Copyright Information:
Copyright© by the American Society for Clinical Pathology.
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