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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.116_slideshow.ppt
February 01, 2006 - .): Lost in Transition
Four hours after arrival, the lab called the ED to report a critical lab result … the patient presented to the ED, the internist noted the abnormal finding when checking the morning lab … 90% of cases left untreated
Delay in plasma exchange due to
Breakdown in communication of serious lab … Failure to Identify Serious Laboratory Abnormality
Most desirable method to deliver critical lab
-
psnet.ahrq.gov/issue/outpatient-adverse-drug-events-identified-screening-electronic-health-records
June 08, 2016 - The highest yield screening algorithms were triggers that identified patients with abnormal lab values … September 25, 2011
Notification of abnormal lab test results in an electronic medical
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psnet.ahrq.gov/issue/diagnostic-stewardship-leveraging-laboratory-improve-antimicrobial-use
March 15, 2023 - December 30, 2014
WebM&M Cases
Amended Lab Results: Communication … Hospitals
Health Care Providers
Pathology and Laboratory Medicine
Missed or Critical Lab
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Singh_69.pdf
April 04, 2008 - Lab
Phone/Fax
Chart
Select Error:
Wrong patient
Wrong medication
Wrong dose
Wrong frequency
Wrong … Lab
Phone/Fax
Chart
StorySeverity
Click Here
(this is
where the
error
occurred)
1 2
Contributing … meds
OTC meds
Past medical history / Problem list
Lab values
Consult reports
Phone messages
Poor chart … Lab
Phone/Fax
Chart
Consequences of Error: Wrong dose
Click on the place where a Consequence occurred … Lab
Phone/Fax
Chart
Consequences of Error: Wrong dose
Please give a brief story
Severity
The story
-
www.ahrq.gov/research/findings/final-reports/crctoolkit/crctoolkit2.html
April 01, 2018 - Establish relationship with a clinical lab. … It must have or develop a business associate relationship with the clinical labs or use a lab it operates … to allow the lab to report screenings and results to the central entity. … Establish relationship with a clinical lab.
Work with colonoscopy providers.
-
psnet.ahrq.gov/node/73905/psn-pdf
October 06, 2021 - Chapel Hill, in partnership with an
interdisciplinary team funded by an AHRQ Patient Safety Learning Lab … , education, and
https://psnet.ahrq.gov//#6
https://www.ahrq.gov/patient-safety/resources/learning-lab … Accessed September 23,
2021. https://www.ahrq.gov/patient-safety/resources/learning-lab/index.html … .0000000000003762
https://doi.org/10.1089/jwh.2020.8882
https://www.ahrq.gov/patient-safety/resources/learning-lab
-
digital.ahrq.gov/sites/default/files/docs/survey/hit-survey.pdf
June 16, 2021 - When I provide primary care for patients with acute
conditions, I can easily access treatment plans, lab … f) I often meet with patients without having lab and test
results I need from other providers. … lt
V
e
ry
D
if
fi
c
u
lt
N
o
t
A
p
p
li
c
a
b
le
a) X-ray reports
b) Lab
-
digital.ahrq.gov/sites/default/files/docs/page/Root.ppt
June 01, 2005 - Click
Labs could automate reporting of lab results for reportable diseases. … E-Prescriptions;
Formularies
Health Care Providers to Payers
Claims, eligibility inquiries; claim status; lab … Data Base E-prescriptions;
refills, renewals,
Prior auth notice; Questions about tests and results Lab … results, reminders disease mgt reminders refill/renewal reminders,
Hospitals Results,; Discharge notes; lab … Clearinghouse
Providers
Hospitals
Clinics
Integrated health care system
Provider
Payers
Laboratories
Lab
-
www.ahrq.gov/es/tools/index.html?page=2
January 01, 2018 - Step-by-Step Guide for Rapid-Cycle Patient Safety and Quality Improvement
The Improving Your Office Lab … Testing Process Ambulatory Toolkit increases the reliability of the lab testing process within a medical
-
digital.ahrq.gov/health-care-theme/health-literacy
January 01, 2023 - LabGenie: A Patient-Engagement Tool to Aid Older Adults' Understanding of Lab … app to support older adults with chronic conditions in comprehending, managing, and acting upon their lab
-
digital.ahrq.gov/health-care-theme/shared-decision-making
January 01, 2023 - LabGenie: A Patient-Engagement Tool to Aid Older Adults' Understanding of Lab … app to support older adults with chronic conditions in comprehending, managing, and acting upon their lab
-
psnet.ahrq.gov/issue/how-well-do-health-professionals-interpret-diagnostic-information-systematic-review
August 03, 2022 - July 13, 2016
Weak oversight allows lab failures to put patients at risk. … April 1, 2009
Hospitals move to cut dangerous lab errors.
-
www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/long-term-care/poster-urine-collection.pdf
June 01, 2021 - • Transport urine samples to the lab within 15
minutes.
-
www.ahrq.gov/sites/default/files/2024-01/field2-report.pdf
January 01, 2024 - Decision by
Clinician with
Patient
Monitor
Obtain information
Order and follow-up on
lab … For example, we needed frequencies for
events such as “lab results are faxed to the wrong office,” “ … clerk fails to enter lab results into the
electronic medical record,” and “prescriber believes s/he … of clinic staff to
tackle these system failures: 1) a Patient Contact Update working group and 2) a Lab … establishment of the “no-show”
committee led to a pilot study to clean the backlog of incompleted lab
-
digital.ahrq.gov/sites/default/files/docs/survey/qualitative-interview-ehr-implementation.pdf
June 16, 2021 - Describe the areas where you think workflow will need to be addressed (lab results,
prescription refills … Describe the areas where you have the most difficulty with workflow (lab results,
prescription refills … Describe how workflow was impacted (lab results, prescription refills, tracking referrals
etc). … Describe how workflow was impacted (lab results, prescription refills, tracking referrals
etc). … Describe how workflow was impacted (lab results, prescription refills, tracking referrals
etc).
-
psnet.ahrq.gov/issue/prone-error-earliest-steps-find-cancer
March 09, 2011 - October 3, 2017
Weak oversight allows lab failures to put patients at risk. … January 20, 2010
Hospitals move to cut dangerous lab errors.
-
www.ahrq.gov/sites/default/files/2024-12/eder-report.pdf
January 01, 2024 - Scope
The scope of this assessment includes the processing of all lab tests, imaging
studies, … number of unique patients, encounters, and clinical staff;
geographic location; and the types of lab … audits and the patient
phone surveys as well as from the audits of all tests and critical abnormal lab … This study yielded quantitative pilot data on areas in the community
health center lab testing process … of patients (68%) who had lab
-
www.ahrq.gov/research/findings/final-reports/crcscreeningrpt/crcscreentab5-1.html
April 01, 2018 - responsibilities, instructions for receiving stool test kits from patients and sending them to the clinical lab … Recruit a stool test kit supplier and a clinical lab to process/develop kits
N/A
Step 2: Conduct
-
psnet.ahrq.gov/web-mm/critical-opportunity-lost
February 17, 2017 - transitioned to a new electronic health record and questions were raised about how critical or panic lab … The Commentary Poor management and workflows in handling important lab results can lead to significant … Critical values are a defined subset of important lab results. … MLO Med Lab Obs. 1972;4:47-54. 2. Clinical Laboratory Improvement Amendments of 1988. … Hospitals
Quality and Safety Professionals
Pathology and Laboratory Medicine
Missed or Critical Lab
-
www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/perinatal-care/modules/situ/simulation_mg-toxicity.docx
May 01, 2017 - Lab result printouts or a simulated patient in the electronic medical record with the necessary lab results