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  1. Psn-Pdf (pdf file)

    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.
  2. Psn-Pdf (pdf file)

    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.
  3. 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
  4. 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
  5. 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.
  6. Psn-Pdf (pdf file)

    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
  7. Psn-Pdf (pdf file)

    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 …
  8. Psn-Pdf (pdf file)

    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.
  9. Psn-Pdf (pdf file)

    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
  10. 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
  11. 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
  12. 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
  13. 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
  14. Psn-Pdf (pdf file)

    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…
  15. psnet.ahrq.gov/issue/interview-donald-berwick
    August 04, 2021 - October 7, 2008 Hospitals move to cut dangerous lab errors.
  16. 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
  17. 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
  18. Psn-Pdf (pdf file)

    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
  19. Psn-Pdf (pdf file)

    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
  20. 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

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