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digital.ahrq.gov/sites/default/files/docs/page/TMS_Lifebook_ver2000.mdb
June 16, 2021 - 11 B1 Computer - Looking For Chart
12 B2 Computer - Looking For Data
13 B3 Computer - Looking For Lab … - Writing Forms
24 C5 Computer - Writing Other
25 D1 Paper - Read Chart
26 D2 Paper - Read Data (Lab … Read Other
35 E1 Paper - Looking For Chart
36 E2 Paper - Looking For Data
37 E3 Paper - Looking For Lab … Patient
50 G2 Procedures EKG
51 G3 Procedures IV
52 G4 Procedures Joint Inj / Asp
53 G5 Procedures Lab
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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.
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psnet.ahrq.gov/node/45944/psn-pdf
August 15, 2018 - Orders on file but no labs drawn: investigation of machine
and human errors caused by an interface idiosyncrasy.
August 15, 2018
Schreiber R, Sittig DF, Ash JS, et al. Orders on file but no labs drawn: investigation of machine and human
errors caused by an interface idiosyncrasy. J Am Med Inform Assoc. 2017;24(5):9…
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psnet.ahrq.gov/node/60680/psn-pdf
July 15, 2020 - missed diagnoses of adolescent depression, elevated blood pressure, and
delayed response to abnormal lab … to recognize and
act on abnormal blood pressure values, and failure to notify families of abnormal lab
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psnet.ahrq.gov/issue/safe-patient-outcomes-occur-timely-standardized-communication-critical-values
January 15, 2020 - March 23, 2012
WebM&M Cases
Amended Lab Results: Communication … Topic
Health Care Providers
Health Care Executives and Administrators
Missed or Critical Lab
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psnet.ahrq.gov/issue/comparison-clinical-diagnoses-and-autopsy-findings-six-year-retrospective-study
March 27, 2024 - Arch Pathol Lab Med. 2017;141(9):1262-1266. doi:10.5858/arpa.2016-0488-oa. … Arch Pathol Lab Med . 2017; 141 (9) :1262-1266 . … Arch Pathol Lab Med. 2017;141(9):1262-1266. doi:10.5858/arpa.2016-0488-oa.
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hcup-us.ahrq.gov/reports/methods/2010_01.pdf
January 01, 2010 - hospitals to participate, identified data elements to add to administrative datasets, standardized
lab … ii
Data standards and transmission
The use of lab data and transmission standards (LOINC, HL7 … Hospital personnel at various levels and in various departments (administrator, lab and
IT personnel … that:
has credibility with clinicians by accurately measuring severity of illness through POA and lab … They were responsible for:
Identifying and selecting clinical data elements (e.g. lab values which
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www.ahrq.gov/research/shuttered/toolkitchecklist/medancillary.html
July 01, 2018 - If the medical personnel determine that locations such as pharmacy or lab could be operational, additional
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol3/Advances-Davis_60.pdf
April 07, 2008 - fragmented care
10 8 9 720
Inconsistent process of ordering
and receiving blood products
and lab … • Mismanagement of
clinical situation
10 10 7 700
Lack of closed-loop
communication with
lab … Latent • Delay in treatment 10 8 1 80
Anesthesiologist in OR not able
to talk directly with the lab … failure mode occurred in
every simulation and resulted in delays in receiving blood and/or critical lab … message that this particular
order is “STAT” and therefore should have the highest priority in the lab
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www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/dx-journey-presenter-notes.pdf
June 02, 2025 - So, I did
the procedure and as per usual sent the
fluid to the lab. … So, I did the procedure and as per usual sent the fluid to the lab. … Phone visit
with PCP
and
appointment
made with
pulmonary
clinic
PCP called
pt: x-ray and
lab
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www.ahrq.gov/sites/default/files/wysiwyg/teamstepps-program/dx-improvement/dx-journey-mr-kane.pptx
June 02, 2025 - So, I did the procedure and as per usual sent the fluid to the lab. … So, I did the procedure and as per usual sent the fluid to the lab. … Oct
PCP called pt: x-ray and lab results from pulm. visit were normal.
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/pruprev/exercises6.html
December 01, 2017 - order for Hospice, the cell shows:
The word "NO"
A dash (-)
Blank
None of the above
Lab … There are no lab dates. Can it be true that the resident has never had lab work?
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psnet.ahrq.gov/issue/attributes-medical-event-reporting-systems
February 14, 2024 - Arch Pathol Lab Med. 1998;122(3):231-8. … Arch Pathol Lab Med . 1998; 122 (3) :231-8 .
View more articles from the same authors. … Arch Pathol Lab Med. 1998;122(3):231-8.
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psnet.ahrq.gov/issue/errors-laboratory-medicine-practical-lessons-improve-patient-safety
February 14, 2024 - Arch Pathol Lab Med. 2005;129(10):1252-1261. … Arch Pathol Lab Med . 2005; 129 (10) :1252-1261 . … Arch Pathol Lab Med. 2005;129(10):1252-1261.
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www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/microbiological-cultures.pdf
June 01, 2021 - Transfer to lab or refrigerator within 15 minutes. … Transfer to the lab or the refrigerator within 15 minutes.
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psnet.ahrq.gov/web-mm/fatal-twist-pseudohyperkalemia
February 10, 2021 - 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 ] Khodorkovsky B, Cambria B, Lesser M, Hahn B.
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psnet.ahrq.gov/web-mm/lp-or-not-lp
February 01, 2018 - parents presented to the ED and said they were there for a "blood test" and were referred to a local lab … At the lab, they were informed that the doctor had not called in any lab test orders. … The lab asked the patient´s family to wait while the physician was called, but while waiting the infant … He was informed that the patient had been sent to the lab and was not seen in the ED. … provider, the ED failed to obtain an adequate history from the patient’s family before sending him to the lab
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psnet.ahrq.gov/issue/identifying-risk-use-tumor-markers-improve-patient-safety
March 09, 2022 - Clin Chem Lab Med. 2016;54(12):1947-1953. doi:10.1515/cclm-2015-0760. … Clin Chem Lab Med . 2016; 54 (12) :1947-1953 . … Clin Chem Lab Med. 2016;54(12):1947-1953. doi:10.1515/cclm-2015-0760.
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psnet.ahrq.gov/issue/impact-interactions-between-drugs-and-laboratory-test-results-diagnostic-test-interpretation
March 06, 2019 - Clin Chem Lab Med. 2018;56(12):2004-2009. doi:10.1515/cclm-2018-0900. … Clin Chem Lab Med . 2018; 56 (12) :2004-2009 . … Clin Chem Lab Med. 2018;56(12):2004-2009. doi:10.1515/cclm-2018-0900.
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psnet.ahrq.gov/issue/pathologists-perspectives-disclosing-harmful-pathology-error
January 22, 2020 - Arch Pathol Lab Med. 2017;141(6):841-845. doi:10.5858/arpa.2016-0136-OA. … Arch Pathol Lab Med . 2017; 141 (6) :841-845 . … Arch Pathol Lab Med. 2017;141(6):841-845. doi:10.5858/arpa.2016-0136-OA.