TABLE 2.

Six cases illustrating the use of the three-stage method for evaluating corrected reports

Corrections made	Stage 1: (corrected reports review) positive?	Stage 2 screen: (medical record review) positive?	Stage 3: clinical investigation including clinician interview
staphylococci changed to Staphylococci	No; cosmetic changes only	Not performed	Not performed
Vaginal swab culture showed 1+ yeast previously not reported	No; presence of normal flora has no impact on management	Not performed	Not performed
Blood culture showed MSSA previously reported as MRSA	Yes; potential for increased level of care and inappropriate treatment	No; records indicate that the patient had died before initial result was released	Not performed
Wound culture Gram stain showed gram-positive cocci previously reported as gram-negative cocci	Yes; potential for delay in appropriate treatment	Yes; medical record contains no information	No adverse clinical impact; clinician confirmed patient was appropriately treated based on earlier culture results
Blood culture showed Acinetobacter species initially reported as Streptococci; susceptibility study showed that the organism was only sensitive to imipenem and tobramycin	Yes, because different antibiotic coverage is required for streptococci and Acinetobacter	Yes; medical record documented that patient had prolonged fever while on ceftriaxone and was subsequently switched to imipenem	Adverse clinical impact was present; the physician confirmed that treatment change was secondary to the correction of the lab report; the error caused delay in appropriate treatment and prolonged patient morbidity
Blood culture showed coagulase-negative staphylococci previously reported as yeast	Yes; patient likely to have received unnecessary antifungal treatment	Yes; incident was not mentioned in the medical record	Adverse clinical impact was present; patient was put on unnecessary antifungal treatment for 2 days