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psnet.ahrq.gov/issue/are-amended-surgical-pathology-reports-getting-correct-responsible-care-provider
September 04, 2024 - March 23, 2012
WebM&M Cases
Amended Lab Results: Communication … Care Providers
Information Professionals
Pathology and Laboratory Medicine
Missed or Critical Lab
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.116_slideshow.ppt
February 01, 2006 - .): Lost in Transition
Four hours after arrival, the lab called the ED to report a critical lab result … the patient presented to the ED, the internist noted the abnormal finding when checking the morning lab … 90% of cases left untreated
Delay in plasma exchange due to
Breakdown in communication of serious lab … Failure to Identify Serious Laboratory Abnormality
Most desirable method to deliver critical lab
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psnet.ahrq.gov/issue/outpatient-adverse-drug-events-identified-screening-electronic-health-records
June 08, 2016 - The highest yield screening algorithms were triggers that identified patients with abnormal lab values … September 25, 2011
Notification of abnormal lab test results in an electronic medical
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psnet.ahrq.gov/issue/diagnostic-stewardship-leveraging-laboratory-improve-antimicrobial-use
March 15, 2023 - December 30, 2014
WebM&M Cases
Amended Lab Results: Communication … Hospitals
Health Care Providers
Pathology and Laboratory Medicine
Missed or Critical Lab
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psnet.ahrq.gov/node/73905/psn-pdf
October 06, 2021 - Chapel Hill, in partnership with an
interdisciplinary team funded by an AHRQ Patient Safety Learning Lab … , education, and
https://psnet.ahrq.gov//#6
https://www.ahrq.gov/patient-safety/resources/learning-lab … Accessed September 23,
2021. https://www.ahrq.gov/patient-safety/resources/learning-lab/index.html … .0000000000003762
https://doi.org/10.1089/jwh.2020.8882
https://www.ahrq.gov/patient-safety/resources/learning-lab
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psnet.ahrq.gov/issue/how-well-do-health-professionals-interpret-diagnostic-information-systematic-review
August 03, 2022 - July 13, 2016
Weak oversight allows lab failures to put patients at risk. … April 1, 2009
Hospitals move to cut dangerous lab errors.
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psnet.ahrq.gov/issue/prone-error-earliest-steps-find-cancer
March 09, 2011 - October 3, 2017
Weak oversight allows lab failures to put patients at risk. … January 20, 2010
Hospitals move to cut dangerous lab errors.
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psnet.ahrq.gov/web-mm/critical-opportunity-lost
February 17, 2017 - transitioned to a new electronic health record and questions were raised about how critical or panic lab … The Commentary Poor management and workflows in handling important lab results can lead to significant … Critical values are a defined subset of important lab results. … MLO Med Lab Obs. 1972;4:47-54. 2. Clinical Laboratory Improvement Amendments of 1988. … Hospitals
Quality and Safety Professionals
Pathology and Laboratory Medicine
Missed or Critical Lab
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psnet.ahrq.gov/web-mm/result-stopped-here
December 01, 2006 - The lab called infection control, who in turn notified the float nurse caring for the patient. … In principle, the optimal choice of a particular lab test as a potential alert and the selection of panic … Arch Pathol Lab Med. 2002;126:663-9.[ go to PubMed ]
9. Lum G. … Ann Clin Lab Sci. 1998;28:261-71.[ go to PubMed ]
10. Tate KE, Gardner RM. … Culture
July 1, 2017
WebM&M Cases
Amended Lab
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psnet.ahrq.gov/issue/getting-results-reliably-communicating-and-acting-critical-test-results
May 24, 2015 - October 7, 2008
Clinical Lab Quality: CMS and Survey Organization Oversight Should Be … Facility and Group Administrators
Pathology and Laboratory Medicine
Missed or Critical Lab
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psnet.ahrq.gov/issue/managing-risk-point-care-preventing-errors
February 06, 2018 - July 16, 2014
WebM&M Cases
Amended Lab Results: Communication … Hospitals
Health Care Providers
Pathology and Laboratory Medicine
Missed or Critical Lab
-
psnet.ahrq.gov/node/49584/psn-pdf
April 01, 2009 - They facilitate:
Easier and more accurate record keeping and scheduling;
Automation of lab orders and … integration of lab reports;
Links to pharmacies (including electronic prescribing) and computerized … unforeseen problems inevitably arise, e.g., a requirement to provide a
diagnostic code to order a lab … If the hospital had installed the full
EMR in that lab, dermatopathologists could review cases and see … of this error because the physician entering the lab results
would have been able to see the patient's
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psnet.ahrq.gov/issue/systematic-review-interventions-follow-test-results-pending-discharge
November 16, 2022 - March 23, 2012
WebM&M Cases
Amended Lab Results: Communication … Providers
Facility and Group Administrators
Pathology and Laboratory Medicine
Missed or Critical Lab
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psnet.ahrq.gov/issue/are-pathologists-self-aware-their-diagnostic-accuracy-metacognition-and-diagnostic-process
May 18, 2022 - March 13, 2019
Weak oversight allows lab failures to put patients at risk. … Pathology and Laboratory Medicine
Diagnostic Test Interpretation Error
Missed or Critical Lab
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psnet.ahrq.gov/issue/checking-checklist
July 11, 2023 - Book/Report
Checking In on the Checklist.
Citation Text:
Checking In on the Checklist. Buissonniere M. Brooklyn NY: Lifebox and Ariadne Labs; 2020.
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psnet.ahrq.gov/node/73906/psn-pdf
October 06, 2021 - population that we serve at UNC Medical Center, which is the site of this Patient Safety Learning
Lab … KH: Tell us a bit about that work as an AHRQ Patient Safety Learning Lab and how your interest in this … KT: [AHRQ’s Patient Safety] Learning Lab is an ideal mechanism for this space because it gives us an … AS: That’s the focus of the Learning Lab, but we’re interested in the whole life, right? … This has grown out of our lab and is now something used across the health system for action.
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psnet.ahrq.gov/node/36840/psn-pdf
June 16, 2019 - examples of problems related to abbreviations,
electronic prescribing, and communication of critical lab
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psnet.ahrq.gov/node/73202/psn-pdf
April 28, 2021 - What was not known to the patient, her clinicians,
or the hospital lab was that the patient’s particular … Contamination at CDC lab delayed rollout of coronavirus tests. Washington Post. 2020. … Available at: https://www.washingtonpost.com/investigations/contamination-at-cdc-lab-…. … Available at: https://www.cdc.gov/coronavirus/2019-ncov/lab/resources/antigen-tests-g…. … Clin Chem Lab Med.
2020;58(12):2131–2140. doi:10.1515/cclm-2020-0978.
35.
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psnet.ahrq.gov/node/37539/psn-pdf
June 16, 2019 - medication error reports provides examples of intravenous amphotericin mix-ups,
cardiac catheterization lab
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psnet.ahrq.gov/issue/eight-recommendations-policies-communicating-abnormal-test-results
March 10, 2011 - March 23, 2012
WebM&M Cases
Amended Lab Results: Communication … Professionals
Organizational Behaviorists
Pathology and Laboratory Medicine
Missed or Critical Lab