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Publication Type: Patient Safety Alert
Single or Multiple Incident: Multiple
Date: 10/6/2020 12:00:00 AM
Country: South Korea
Following a biopsy of a mass on the left elbow, a patient was discharged from hospital and was to be contacted following a pathological test of the sample. The biopsy result was confirmed as a malignant tumor two weeks later but was not classified as a critical value report (CVR). As a result, the diagnosis was omitted from the report to the physician and not discovered until six months later causing a significant delay in treatment for the patient. Recommendations and examples of related preventive activities are included to prevent patient safety incidents that cause disturbance of precise diagnosis and delay of treatment due to a lack of action taken immediately on the result of CVR.


Rules / Policies / Procedures
  1. There should be a procedure for safe reporting of the results
  2. Test result of the laboratory, diagnostic imaging should be reported accurately and quickly.
  3. CVR of the test should be carried out.
  4. The intermediate result is to be reported in case of the sample test.
  5. Any change on the reported result of the test should be reported to the relevant medical staff immediately.

Delay or Omission of Critical Value Report (CVR)