Michael Laposata, M.D., Ph.D. Director of Clinical Laboratories ...

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Test related errors outside MGH – which laterpresented at MGH and were detected at that timeYoung father accused of shaking his baby –child had significant bleeding disordermissed by ordering clinician who mistakenlyinterpreted test results forvon Willebrands disease.Outcome-Father imprisoned, parents divorced
Test related errors outside MGH – which laterpresented at MGH and were detected at that time33 year old pregnant woman told she hassevere risk for thrombosis because of lowProtein S value. Clinician did not knowProtein S is lowered in most pregnancieswithout risk of thrombosis.Outcome - Woman terminates a normalpregnancy she desperately wanted to keep.
Page 1 and 2: Michael Laposata, M.D., Ph.D.Direct
Page 4 and 5: What points in the process have the
Page 8 and 9: Increased cost ofcare from lab test
Page 13 and 14: STRATEGY #1Use reflex testing asmuc
Page 15 and 16: MGH experience with detectable erro
Page 18 and 19: STRATEGY #2Provide patient-specific
Page 20 and 21: 1996 Survey of MGH physician experi
Page 22 and 23: THIS INTERPRETATION PROBABLYREDUCED
Page 24 and 25: DO YOU FIND THESEINTERPRETATIONS US
Page 26 and 27: Interpretation Impact - Physician O
Page 28 and 29: Interpretation Impact - FinancialSa
Page 30 and 31: CONSERVATIVE ESTIMATE OF SAVINGSFRO
Page 32 and 33: BARRIERS TO IMPLEMENTATION OFPROGRA
Page 34 and 35: STRATEGY #3Create a national group
Page 36 and 37: PERCEIVED CAUSES OFPREVENTABLE MEDI
Page 38 and 39: POSSIBLE SOLUTIONS TO THE MEDICAL E

Michael Laposata, M.D., Ph.D. Director of Clinical Laboratories ...

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