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psnet.ahrq.gov/issue/surgical-specimen-management-descriptive-study-648-adverse-events-and-near-misses
December 22, 2021 - Arch Pathol Lab Med. 2016;140(12):1390-1396. … Arch Pathol Lab Med . 2016; 140 (12) :1390-1396 . … Arch Pathol Lab Med. 2016;140(12):1390-1396. … Health Care Providers
Pathology and Laboratory Medicine
Diagnostic Errors
Missed or Critical Lab
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psnet.ahrq.gov/issue/point-care-testing-medical-error-and-patient-safety-2007-assessment
February 01, 2017 - Clin Chem Lab Med. 2007;45(6):766-73. … Clin Chem Lab Med . 2007; 45 (6) :766-73 .
View more articles from the same authors. … Clin Chem Lab Med. 2007;45(6):766-73. … July 23, 2008
Hospitals move to cut dangerous lab errors.
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psnet.ahrq.gov/issue/reducing-diagnostic-errors-worldwide-through-diagnostic-management-teams
May 23, 2018 - Ann Lab Med. 2019;39(2):121-124. doi:10.3343/alm.2019.39.2.121. … Ann Lab Med . 2019; 39 (2) :121-124 .
View more articles from the same authors. … Ann Lab Med. 2019;39(2):121-124. doi:10.3343/alm.2019.39.2.121. … February 15, 2010
Hospitals move to cut dangerous lab errors.
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psnet.ahrq.gov/issue/current-and-ideal-state-anatomic-pathology-patient-safety
February 15, 2010 - MLO Med Lab Obs. 2014;46(6):8-10. … MLO Med Lab Obs . 2014; 46 (6) :8-10 .
View more articles from the same authors. … MLO Med Lab Obs. 2014;46(6):8-10. … January 8, 2016
Weak oversight allows lab failures to put patients at risk.
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psnet.ahrq.gov/issue/quality-improvement-decrease-specimen-mislabeling-transfusion-medicine
September 11, 2024 - Arch Pathol Lab Med. 2006;130(8):1196-1198. … Arch Pathol Lab Med . 2006; 130 (8) :1196-1198 . … Arch Pathol Lab Med. 2006;130(8):1196-1198.
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psnet.ahrq.gov/node/866618/psn-pdf
December 31, 2024 - The lab sample was reported as
hemolyzed, but this finding was not recognized by the treating physician … These findings could
have prompted the physician to question the validity of the lab measurement. … and/or the EHR interface to affirm acknowledgment of hemolyzed lab samples. … Inconsistent findings should prompt consideration of lab error (e.g.,
pseudohyperkalemia). … J
Appl Lab Med. 2020;5(2):332-341. [Free full text]
4.
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psnet.ahrq.gov/node/50949/psn-pdf
February 26, 2020 - Lab
Med 2012;43:41-44.
3. … Arch Pathol Lab Med
2010;134:1108–15.
9. … J App Lab Med 2019;4:229-234.
12. … Arch Pathol Lab Med
2010;134:244-255.
18. Nakhleh RE. … Arch Pathol Lab Med 2019;143 [epub ahead of print].
20. Fisher JA, Monahan T.
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psnet.ahrq.gov/node/840255/psn-pdf
November 16, 2022 - Madison, WI
https://psnet.ahrq.gov//#_edn9
https://www.ahrq.gov/patient-safety/resources/learning-lab … /index.html
https://www.ahrq.gov/patient-safety/resources/learning-lab/index.html
https://psnet.ahrq.gov … brain-health-long-desc.html
https://psnet.ahrq.gov//#_edn12
https://www.ahrq.gov/patient-safety/resources/learning-lab … /failure-rescue-long-desc.html
https://www.ahrq.gov/patient-safety/resources/learning-lab/imaging-quality-long-desc.html … https://www.ahrq.gov/patient-safety/resources/learning-lab/imaging-quality-long-desc.html
Nicole Werner
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psnet.ahrq.gov/issue/patient-misidentification-laboratory-medicine-qualitative-analysis-227-root-cause-analysis
August 28, 2024 - Arch Pathol Lab Med. 2010;134(2):244-255. doi:10.1043/1543-2165-134.2.244. … Arch Pathol Lab Med . 2010; 134 (2) :244-255 . … Arch Pathol Lab Med. 2010;134(2):244-255. doi:10.1043/1543-2165-134.2.244.
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psnet.ahrq.gov/issue/accuracy-send-out-test-ordering-college-american-pathologists-q-probes-study-ordering
November 12, 2008 - Arch Pathol Lab Med. 2008;132(2):206-10. doi:10.1043/1543-2165(2008)132[206:AOSTOA]2.0.CO;2. … Arch Pathol Lab Med . 2008; 132 (2) :206-10 . … Arch Pathol Lab Med. 2008;132(2):206-10. doi:10.1043/1543-2165(2008)132[206:AOSTOA]2.0.CO;2. … See More About The Topic
Pathology and Laboratory Medicine
Missed or Critical Lab
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psnet.ahrq.gov/issue/notification-abnormal-lab-test-results-electronic-medical-record-do-any-safety-concerns
April 04, 2011 - Study
Classic
Notification of abnormal lab test results … Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain … Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain
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psnet.ahrq.gov/issue/quality-and-safety-medical-care-what-does-future-hold
September 18, 2019 - Arch Pathol Lab Med. 2011;135(11):1425-31. doi:10.5858/arpa.2011-0154-OA. … Arch Pathol Lab Med . 2011; 135 (11) :1425-31 . … Arch Pathol Lab Med. 2011;135(11):1425-31. doi:10.5858/arpa.2011-0154-OA.
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psnet.ahrq.gov/issue/error-tracking-clinical-biochemistry-laboratory
June 10, 2020 - Clin Chem Lab Med. 2009;47(10). doi:10.1515/cclm.2009.272. … Clin Chem Lab Med . 2009; 47 (10) .
View more articles from the same authors. … Clin Chem Lab Med. 2009;47(10). doi:10.1515/cclm.2009.272.
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psnet.ahrq.gov/issue/patient-safety-clinical-laboratory-longitudinal-analysis-specimen-identification-errors
March 19, 2019 - Arch Pathol Lab Med. 2006;130(11):1662-1668. … Arch Pathol Lab Med . 2006; 130 (11) :1662-1668 . … Arch Pathol Lab Med. 2006;130(11):1662-1668.
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psnet.ahrq.gov/issue/identification-errors-pathology-and-laboratory-medicine
October 19, 2022 - Clin Lab Med. 2004;24(4):979-96, vii. … Clin Lab Med . 2004; 24 (4) :979-96, vii .
View more articles from the same authors. … Clin Lab Med. 2004;24(4):979-96, vii.
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psnet.ahrq.gov/issue/opportunities-enhance-laboratory-professionals-role-diagnostic-team
April 13, 2022 - Lab Med. 2017;48(1):97-103. doi:10.1093/labmed/lmw048. … Lab Med . 2017; 48 (1) :97-103 .
View more articles from the same authors. … Lab Med. 2017;48(1):97-103. doi:10.1093/labmed/lmw048.
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psnet.ahrq.gov/issue/intraoperative-communications-between-pathologists-and-surgeons-do-we-understand-each-other
June 28, 2023 - Arch Pathol Lab Med. 2023;147(8):933-939. doi:10.5858/arpa.2020-0632-oa. … Arch Pathol Lab Med . 2023; 147 (8) :933-939 . … Arch Pathol Lab Med. 2023;147(8):933-939. doi:10.5858/arpa.2020-0632-oa.
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psnet.ahrq.gov/issue/finding-blunders-thyroid-testing-experience-newborns
March 04, 2020 - J Clin Lab Anal. 2008;22(4):254-6. doi:10.1002/jcla.20247. … J Clin Lab Anal . 2008; 22 (4) :254-6 .
View more articles from the same authors. … J Clin Lab Anal. 2008;22(4):254-6. doi:10.1002/jcla.20247.
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psnet.ahrq.gov/web-mm/say-it-again
January 31, 2020 - It was unclear if a "read-back" occurred between the lab tech and the charge nurse, who was covering … best practice" satisfies both goals simultaneously; that is, engaging in a read-back to ensure that lab … Proposed "Best Practice" for a read-back of critical lab values Lab Tech: Hello. … This is Larry Hastings in the lab. Are you responsible for Harold Jackson, age 72? … Lab Tech: Correct. Thanks for the confirmation.
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psnet.ahrq.gov/node/49527/psn-pdf
December 01, 2006 - Arch Pathol Lab
Med. 2005;129:1252–1261. [go to PubMed]
6. Valenstein PN, Raab SS, Walsh MK. … Arch
Pathol Lab Med. 2006;130:1106–1113 [go to PubMed]
7. … Arch Pathol Lab Med. 2002;126:663–669. [go to
PubMed]
9. Howanitz PJ, Renner SW, Walsh MK. … Arch Pathol Lab Med.
2002;126:809–815. [go to PubMed]
10. … Lab Errors Patient Saf. 2005;1:9–11.
15. Bologna LJ, Mutter M.