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psnet.ahrq.gov/issue/payment-innovations-improve-diagnostic-accuracy-and-reduce-diagnostic-error
December 16, 2020 - pathway to diagnostic excellence: the challenges and successes of implementing the Safer Dx Learning Lab
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psnet.ahrq.gov/issue/developing-health-care-organizations-pursue-learning-and-exploration-diagnostic-excellence
October 28, 2020 - pathway to diagnostic excellence: the challenges and successes of implementing the Safer Dx Learning Lab
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psnet.ahrq.gov/issue/diagnostic-errors-neonatal-intensive-care-unit-state-science-and-new-directions
March 23, 2022 - pathway to diagnostic excellence: the challenges and successes of implementing the Safer Dx Learning Lab
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psnet.ahrq.gov/issue/application-who-surgical-safety-checklist-outside-operating-theatre-medicine-can-learn
March 17, 2021 - team communication: closing the loop on quality improvement efforts in the cardiac catheterization lab
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psnet.ahrq.gov/issue/revisiting-old-slides-how-worthwhile-it
October 05, 2022 - February 18, 2009
Clinical Lab Quality: CMS and Survey Organization Oversight Should
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psnet.ahrq.gov/issue/exaggerated-benefits-failure
November 09, 2022 - pathway to diagnostic excellence: the challenges and successes of implementing the Safer Dx Learning Lab
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psnet.ahrq.gov/issue/mind-sentinel-applying-patient-safety-paradigms-clinician-well-being
October 19, 2022 - pathway to diagnostic excellence: the challenges and successes of implementing the Safer Dx Learning Lab
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psnet.ahrq.gov/issue/need-closed-loop-systems-management-abnormal-test-results
May 20, 2019 - Ambulatory Care
Physicians
Facility and Group Administrators
Primary Care
Missed or Critical Lab
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psnet.ahrq.gov/issue/technical-mistakes-during-acquisition-electrocardiogram
March 09, 2022 - team communication: closing the loop on quality improvement efforts in the cardiac catheterization lab
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psnet.ahrq.gov/issue/identifying-patients-whose-symptoms-are-underrecognized-during-treatment-breast-radiotherapy
May 25, 2022 - team communication: closing the loop on quality improvement efforts in the cardiac catheterization lab
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psnet.ahrq.gov/issue/high-reliability-organization-mindset
April 01, 2020 - pathway to diagnostic excellence: the challenges and successes of implementing the Safer Dx Learning Lab
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psnet.ahrq.gov/node/49571/psn-pdf
October 01, 2008 - My own lab surveillance list for growth
insufficiency includes: complete blood count (CBC), erythrocyte
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psnet.ahrq.gov/issue/bring-back-autopsy
September 06, 2016 - October 25, 2017
Weak oversight allows lab failures to put patients at risk.
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psnet.ahrq.gov/issue/focus-health-care-policy-and-quality
November 19, 2014 - Facility and Group Administrators
Radiology
Radiograph Interpretation Error
Missed or Critical Lab
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psnet.ahrq.gov/issue/diagnostic-safety-toolkit-0
January 01, 2019 - pathway to diagnostic excellence: the challenges and successes of implementing the Safer Dx Learning Lab
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psnet.ahrq.gov/issue/handbook-patient-safety-compliance-practical-guide-health-care-organizations
February 07, 2019 - January 4, 2009
Clinical Lab Quality: CMS and Survey Organization Oversight Should Be
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psnet.ahrq.gov/issue/high-cost-low-morale-clinical-laboratory-how-workplace-environment-impacts-patient-safety
March 06, 2005 - Pathology and Laboratory Medicine
Psychological and Social Complications
Missed or Critical Lab
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.275_slideshow.ppt
August 01, 2012 - residents, 46% stated that, at least a few times a year, they have seen a patient worsen due to delays in lab
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.245_slideshow.ppt
July 01, 2011 - patients newly started on warfarin
18
Take-Home Points (2)
Standardizing systems of care through lab … warfarin to newer oral anticoagulants, particularly for patients with unstable INRs or those in whom lab
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psnet.ahrq.gov/node/49679/psn-pdf
March 01, 2013 - The Unfamiliar Catheter
March 1, 2013
Swayze SC, James A. The Unfamiliar Catheter. PSNet [internet]. 2013.
https://psnet.ahrq.gov/web-mm/unfamiliar-catheter
The Case
A 28-year-old woman, 20 months post–bilateral lung transplant, presented to the emergency department
with sudden onset of severe shortness of breath…