title: Using the electronic medical record to better define "no products of conception" as a critical value in anatomic pathology.
abstract: At present, the College of American Pathologists checklist requires documentation of communication of critical values in anatomic pathology to caregivers. Recently, our institution has begun using the electronic medical record to document the lack of imminent danger or emergency associated with the case rather than calling the caregiver. I sought to document this trend. The results of all critical values and all endometrial curettings with a diagnosis of "no products of conception seen" for the last 3 years at 1 hospital were reviewed. During the first 18 months, 0 of 11 critical cases were documented by reference to the electronic medical record. During the second 18 months 5 of 14 cases (36%; P = .02) were documented to have an intrauterine pregnancy by ultrasound and the physician was not notified. In our laboratory, cases without products of conception and a documented intrauterine pregnancy are no longer considered critical values in anatomic pathology. Documentation of the lack of imminent danger to the patient through reference to the electronic medical record is an increasingly common and acceptable means of ensuring patient safety and more accurately defining critical values in anatomic pathology.
authors.affiliation: Department of Pathology, Baptist Hospital, Miami, FL 33176, USA.
authors.forename: Andrew
authors.initials: A
authors.lastname: Renshaw
mesh_terms: D000022:Abortion, Spontaneous / Q000175:diagnosis*; D003951:Diagnostic Errors / Q000517:prevention & control; D019937:Diagnostic Techniques and Procedures; D030881:Disclosure; D004282:Documentation / Q000592:standards*; D057286:Electronic Health Records; D005260:Female; D006801:Humans; D010340:Pathology, Surgical / Q000592:standards*; D061214:Patient Safety; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D012016:Reference Values; D009626:Terminology as Topic