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psnet.ahrq.gov/issue/rate-occult-specimen-provenance-complications-routine-clinical-practice
January 05, 2012 - January 7, 2015
Laboratory test ordering and results management systems: a qualitative … January 18, 2013
Voluntary electronic reporting of laboratory errors: an analysis of … 37,532 laboratory event reports from 30 health care organizations. … January 14, 2011
Classifying laboratory incident reports to identify problems that jeopardize … Hospitals
Risk Managers
Quality and Safety Professionals
Safety Scientists
Pathology and Laboratory
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psnet.ahrq.gov/issue/patient-safety-anatomic-pathology-measuring-discrepancy-frequencies-and-causes
January 08, 2016 - surgical pathology and cytology: guideline from the College of American Pathologists Pathology and Laboratory … January 8, 2016
Specimen labeling errors: a Q-probes analysis of 147 clinical laboratories … October 7, 2011
Errors in a stat laboratory: changes in type and frequency since 1996 … September 9, 2011
Patient safety in the clinical laboratory: a longitudinal analysis … July 23, 2008
Computer-assisted bar-coding system significantly reduces clinical laboratory
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psnet.ahrq.gov/node/43939/psn-pdf
February 25, 2015 - indicators to compare point-of-care testing
errors in a neonatal unit and errors in a STAT central
laboratory … indicators to compare point-of-care testing errors in
a neonatal unit and errors in a STAT central laboratory … single neonatal unit, point-of-care testing resulted in many more quality errors compared
to central laboratory … point-care-testing-error-sources-and-amplifiers-taxonomy-prevention-strategies-and-detection
https://psnet.ahrq.gov/issue/computer-assisted-bar-coding-system-significantly-reduces-clinical-laboratory-specimen
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psnet.ahrq.gov/web-mm/delayed-diagnosis-and-treatment-systemic-lupus-erythematosus-psychiatric-presentation
September 27, 2023 - Similarly, several laboratory studies are routinely performed in this setting, as vitamin deficiencies … Other laboratory studies can be ordered secondarily, depending on the clinical context of presentation … It is unclear why obviously abnormal laboratory studies were not acted upon to effectuate the needed … Failure to follow-up on abnormal laboratory results is not an uncommon system or process error and … If a critical laboratory result has not been reviewed within a certain time period, automatic prompts
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psnet.ahrq.gov/issue/determination-unnecessary-blood-transfusion-comprehensive-15-hospital-record-review
October 27, 2021 - researchers identified high rates of unnecessary blood transfusions, primarily attributed to overreliance on laboratory … April 12, 2011
Patient misidentification in laboratory medicine: a qualitative analysis … View More
See More About The Topic
Hospitals
Medicine
Pathology and Laboratory
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psnet.ahrq.gov/issue/anatomy-cyberattack-part-4-quality-assurance-and-error-reduction-billing-and-compliance
April 27, 2022 - This article outlines the laboratory service’s processes during the shutdown, including patient safety … May 26, 2021
Prevalence and predictability of low-yield inpatient laboratory diagnostic … About The Topic
Hospitals
Information Professionals
Hospital Medicine
Pathology and Laboratory
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psnet.ahrq.gov/issue/improving-patient-safety-avoiding-unread-imaging-exams-national-va-enterprise-electronic
March 12, 2025 - June 21, 2023
Interventions to improve follow-up of laboratory test results pending at … Opportunity Lost
March 1, 2015
Patient identification errors: the detective in the laboratory … 22, 2014
Impact of health information technology interventions to improve medication laboratory … About The Topic
Hospitals
Health Care Providers
Information Professionals
Pathology and Laboratory
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psnet.ahrq.gov/issue/assigning-responsibility-close-loop-radiology-test-results
April 03, 2024 - April 3, 2019
Diagnostic stewardship—leveraging the laboratory to improve antimicrobial … September 30, 2011
Decreasing mislabeled laboratory specimens using barcode technology … 2, 2011
Impact of health information technology interventions to improve medication laboratory … More
See More About The Topic
Hospitals
Health Care Providers
Pathology and Laboratory
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psnet.ahrq.gov/node/73336/psn-pdf
May 26, 2021 - Cerebrospinal fluid from a lumbar puncture had a negative
Venereal Disease Research Laboratory (VDRL … Laboratory results included a non-reactive RPR, reactive TPPA, and Treponema pallidum
Immunoglobulin … (VDRL) test, was the first test performed.13 However, in the past decade, most laboratories have
shifted … However, he was not notified of his own laboratory test results,
which were—presumably—abnormal. … Syphilis testing algorithms using treponemal
tests for initial screening--four laboratories, New York
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psnet.ahrq.gov/web-mm/fatal-twist-pseudohyperkalemia
February 10, 2021 - Lewis, MD This case illustrates how the misinterpretation of a common laboratory complication can lead … errors and affecting up to 12% of all samples sent to clinical laboratories, especially in busy clinical … Unwinding the Case Despite the laboratory report of hyperkalemia, the patient presented with several … In non-urgent situations, laboratory testing through the core laboratory should be encouraged over point-of-care … Educational case: hemolysis and lipemia interference with laboratory testing.
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psnet.ahrq.gov/issue/trigger-alerts-associated-laboratory-abnormalities-identifying-potentially-preventable
August 30, 2017 - Study
Trigger alerts associated with laboratory abnormalities on identifying potentially … Trigger alerts associated with laboratory abnormalities on identifying potentially preventable adverse … Trigger alerts associated with laboratory abnormalities on identifying potentially preventable adverse … September 1, 2016
Impact of non-interruptive medication laboratory monitoring alerts
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psnet.ahrq.gov/issue/effect-clinical-decision-support-pending-laboratory-results-emergency-department-discharge
April 24, 2018 - Study
The effect of a clinical decision support for pending laboratory results at … The Effect of a Clinical Decision Support for Pending Laboratory Results at Emergency Department Discharge … The Effect of a Clinical Decision Support for Pending Laboratory Results at Emergency Department Discharge … March 13, 2019
Emergency physicians' views of direct notification of laboratory and radiology
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psnet.ahrq.gov/issue/potential-false-positive-results-antigen-tests-rapid-detection-sars-cov-2-letter-clinical
April 08, 2020 - for false positive results with antigen tests for rapid detection of SARS-CoV-2--letter to clinical laboratory … for false positive results with antigen tests for rapid detection of SARS-CoV-2--letter to clinical laboratory … for false positive results with antigen tests for rapid detection of SARS-CoV-2--letter to clinical laboratory
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psnet.ahrq.gov/issue/detecting-adverse-drug-reactions-paediatric-wards-intensified-surveillance-versus
May 10, 2023 - adverse drug reactions on paediatric wards: intensified surveillance versus computerised screening of laboratory … adverse drug reactions on paediatric wards: intensified surveillance versus computerised screening of laboratory … adverse drug reactions on paediatric wards: intensified surveillance versus computerised screening of laboratory
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psnet.ahrq.gov/issue/disclosing-harmful-pathology-errors-patients
May 18, 2022 - May 18, 2022
Communicating pathology and laboratory errors: anatomic pathologists' and … laboratory medical directors' attitudes and experiences. … November 28, 2016
Error disclosure in pathology and laboratory medicine: a review of … See More About The Topic
Health Care Providers
Organizational Behaviorists
Pathology and Laboratory
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psnet.ahrq.gov/web-mm/contaminated-or-not-guidelines-interpretation-positive-blood-cultures
November 16, 2022 - The routine laboratory tests done that day revealed only a normocytic anemia. … His physical examination and laboratory test results were unremarkable. … Because approximately half of all positive blood cultures in most institutions represent contamination, laboratories … Wayne, PA: Clinical and Laboratory Standards Institute; 2007. ISBN: 1562386417.
12. … Laboratory and epidemiologic observations.
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psnet.ahrq.gov/issue/directed-peer-review-surgical-pathology
December 03, 2014 - Peer review, or second opinion, is used by many laboratories to improve diagnostic accuracy and precision … RIS
Download Citation
Related Resources From the Same Author(s)
Laboratory … April 16, 2014
Direct reporting of laboratory test results to patients by mail to enhance … February 15, 2010
Error tracking in a clinical biochemistry laboratory. … More
See More About The Topic
Quality and Safety Professionals
Pathology and Laboratory
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psnet.ahrq.gov/issue/anatomy-failure-sociotechnical-evaluation-laboratory-physician-order-entry-system
April 13, 2022 - Study
Anatomy of a failure: a sociotechnical evaluation of a laboratory physician … Anatomy of a failure: a sociotechnical evaluation of a laboratory physician order entry system implementation … Anatomy of a failure: a sociotechnical evaluation of a laboratory physician order entry system implementation
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psnet.ahrq.gov/sites/default/files/2020-02/final_spotlight_opat_powerpoint_01102020_tocme.pdf
January 01, 2020 - recommendation for a follow-up appointment at the
Infectious Diseases clinic, and although follow-up laboratory … The post discharge follow-up laboratory tests that had been
ordered were not available in the medical … monitoring based on choice of IV antibiotic and
duration of therapy
• A minimum of once weekly laboratory … The
physician assesses laboratory tests and follows patients in
clinic during the course of treatment … – Appropriate IV access must be established, laboratory
monitoring must be ordered
– It must be clear
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.275_slideshow.ppt
August 01, 2012 - He came to learn that a fax of the laboratory results had been sent to the clinic on Saturday with the … Missed hypothyroidism diagnosis uncovered by linking laboratory and pharmacy data. … tests have been completed
Highlighting laboratory test results that require urgent attention
Presenting … test results is fairly common and can lead to patient harm
Barriers to effective management of laboratory … test results are time pressures and cognitive overload on clinicians
Inadequate laboratory test result