Clinical Lab Tests and Patient Errors-Who is Responsible?

The Agency for Healthcare Research and Quality is seeking approval from the federal government for a new reporting system concerning medical errors. AHRQ Director Carolyn M. Clancy, M.D., told The New York Times in a story published on September 22, 2012, “Currently there is no mechanism for consumers to report information about patient safety events,” she said.
Such a reporting system, if effective, may lead to a reduction in the prevalence and cost of medical errors. One area of concern for patient safety advocates remains the relationship between medical errors and communication failures among doctors and clinical labs.
Dark Daily, a media source reporting laboratory and pathology news and trends, asks some important questions to be addressed by the new reporting system, “But what happens when a patient is misdiagnosed because a patient’s physician reads a medical laboratory test report incorrectly?
And who is to blame if physicians discharge a hospitalized patient before reviewing lab results and the patient dies later? A child died earlier this year after being sent home before the treating physician had reviewed the clinical lab test results, according to a report in the New York Times in July. This child’s death might have been prevented if the hospital staff had reviewed the clinical laboratory test results before the patient was discharged, the newspaper reported.
In adverse events, is it possible that the hospitals’ clinical laboratories could be cited for having some role, even though some observers might suggest that the labs’ involvement was secondary to the causes of these errors? AHRQ has not yet addressed this question.
For its part, the AHRQ suggested that patients or relatives could report errors on a website or over the telephone, the New York Times reported. Therefore, under the AHRQ proposal, a medical laboratory might be implicated if patients and their relatives report medical errors. For each adverse event, the government would collect such information as when and where the harm occurred, the type of harm, any contributing factors, and whether the patient reported the event and to whom, the newspaper reported.”