AHRQ’s Web M&M Explores Risk in Hospital Transfers

The current issue of AHRQ Web M&M features a Spotlight Case involving a man who was sent to another hospital for surgery after a computed tomography (CT) scan revealed renal cell carcinoma in his right kidney. The original CT scan was not available at the time of the transfer. However, hospital records that were sent documented that the tumor was in his left kidney. The second hospital didn’t obtain repeat imaging, and the surgeon did not see the original CT scan before removing the wrong kidney. The day after the surgery, the pathologist contacted the surgeon to report no evidence of cancer. The surgeon then reviewed the initial CT scan and realized the mistake. The issue also features an interview with Brian Jarman, Ph.D., professor emeritus at the Imperial College of Medicine in London, about risk-adjusted mortality as a safety and quality measure. In the Perspectives section of the issue, an article by Ian Scott, M.B.B.S., M.H.A., MEd, of the University of Queensland, Brisbane, Australia, talks about where risk-adjusted mortality rates as a measure of hospital safety.