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psnet.ahrq.gov/node/42178/psn-pdf
April 10, 2013 - Arch Pathol Lab Med. 2013;137(2):233-40. doi:10.5858/arpa.2012-0088-OA.
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psnet.ahrq.gov/node/44544/psn-pdf
October 07, 2015 - Most of these events tended to be mild, such as
symptoms or asymptomatic lab test abnormalities.
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psnet.ahrq.gov/perspective/conversation-gordon-schiff-md
February 26, 2025 - We looked at the history and physical, lab testing, assessment, and follow-up. … In terms of cognitive support and visual display, think about what a profound display tool the lab flowsheet … was, especially well-designed displays where you could see patient's lab values over time and abnormal … We should be talking to the lab staff and we should be talking to radiologist, so maybe the computer … A very special patient of mine had a lung nodule, the lab called me about the chest x-ray showing an
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psnet.ahrq.gov/web-mm/lost-transition
November 17, 2010 - & Commentary: Part 2 Four hours after arrival, the laboratory called the ED to report a critical lab … passed on to, but neither the ED attending nor the internal medicine service was made aware of this lab … the patient presented to the ED, the internist noted the abnormal finding when checking the morning lab … two major mishaps resulted in late administration of plasma exchange, the communication of serious lab
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psnet.ahrq.gov/issue/using-good-design-eliminate-medical-errors
December 09, 2020 - June 21, 2017
Weak oversight allows lab failures to put patients at risk.
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psnet.ahrq.gov/node/43452/psn-pdf
August 20, 2014 - psnet.ahrq.gov/issue/piece-my-mind-copy-and-paste
https://psnet.ahrq.gov/issue/notification-abnormal-lab-test-results-electronic-medical-record-do-any-safety-concerns
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psnet.ahrq.gov/node/50874/psn-pdf
February 05, 2020 - Checking In on the Checklist.
February 5, 2020
Buissonniere M. Brooklyn NY: Lifebox and Ariadne Labs; 2020.
https://psnet.ahrq.gov/issue/checking-checklist
Checklists are integrated into error reduction strategies and healthcare team communication efforts
worldwide but implementation and impact of the tool varies …
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psnet.ahrq.gov/node/49812/psn-pdf
November 01, 2017 - Arch Pathol Lab
Med. 2005;129:1252-1261. [go to PubMed]
4. Dekker SW, ed. … Clin Lab Med. 2004;24:913-
943. [go to PubMed]
7. WHO Surgical Safety Checklist. … Liability and the lab. Lost specimens. Medical Laboratory Observer. September 2007.
Table
Table.
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psnet.ahrq.gov/node/73398/psn-pdf
June 30, 2021 - her
professional capacity, she serves as Principal Investigator for an AHRQ Patient Safety Learning Lab … conversation-anjali-joseph-phd-edac-and-molly-m-scanlon-phd-faia-facha
https://www.ahrq.gov/patient-safety/resources/learning-lab … /index.html
https://www.ahrq.gov/patient-safety/resources/learning-lab/index.html
environment. … I have been leading an Agency
for Healthcare Research and Quality Patient Safety Learning Lab project … , they shifted to negative pressure ORs and
https://www.ahrq.gov/patient-safety/resources/learning-lab
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psnet.ahrq.gov/issue/avoiding-second-wave-medical-errors-importance-human-factors-context-pandemic
March 09, 2022 - Using a case of mislabeled lab specimens as an example, this article highlights the impact of the COVID
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psnet.ahrq.gov/issue/developing-cancer-specific-trigger-tool-identify-treatment-related-adverse-events-using
May 20, 2020 - The most prevalent triggers were abnormal lab test results, blood transfusions, orders for non-contrast
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psnet.ahrq.gov/issue/multicomponent-pharmacist-intervention-did-not-reduce-clinically-important-medication-errors
March 17, 2021 - three phone calls, electronic health record communication with the prescriber, and recommendations for lab
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psnet.ahrq.gov/issue/effect-electronic-health-records-ambulatory-care-retrospective-serial-cross-sectional-study
March 24, 2019 - Kaiser Permanente’s patient population, investigators collected data on utilization of office visits, lab
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psnet.ahrq.gov/node/74019/psn-pdf
July 11, 2023 - PACT Collaborative: Pathway to Accountability,
Compassion and Transparency.
July 11, 2023
Ariadne Labs, Brigham and Women’s Hospital, Harvard TH Chan School of Public Health.
https://psnet.ahrq.gov/issue/pact-collaborative-pathway-accountability-compassion-and-transparency
Communication and Resolution Programs (CR…
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psnet.ahrq.gov/issue/interview-donald-berwick
August 04, 2021 - October 7, 2008
Hospitals move to cut dangerous lab errors.
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psnet.ahrq.gov/issue/classifying-laboratory-incident-reports-identify-problems-jeopardize-patient-safety
May 13, 2020 - Managers
Quality and Safety Professionals
Pathology and Laboratory Medicine
Missed or Critical Lab
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psnet.ahrq.gov/issue/advancing-safety-closed-loop-communication-test-results
November 13, 2019 - Health Care Executives and Administrators
Medicine
Clinical Misdiagnosis
Missed or Critical Lab
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psnet.ahrq.gov/node/860049/psn-pdf
January 04, 2024 - reflected this positive result, and all
subsequent daily progress notes included the phrase, “awaiting lab … important details that contribute to diagnostic error
or delays.4 In this case, the phrase “awaiting lab … Notification of abnormal lab test results in an electronic medical
record: Do any safety concerns remain
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psnet.ahrq.gov/node/43712/psn-pdf
December 03, 2014 - frequency-missed-test-results-and-associated-treatment-delays-highly-computerized-health
https://psnet.ahrq.gov/issue/notification-abnormal-lab-test-results-electronic-medical-record-do-any-safety-concerns
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psnet.ahrq.gov/perspective/conversation-vineet-arora-md-mapp
May 31, 2023 - care panel, but I see what the residents and my colleagues face in managing huge numbers of incoming lab … Even just managing a panel of hospitalized patients, my in-basket is overwhelmed with lab results from … opposed to having clinicians try to adapt their brain and do the work to figure out which abnormal lab