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Contaminated or Not? Guidelines for Interpretation of Positive Blood Cultures | PSNet

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November 16, 2022 - His physical examination and laboratory test results were unremarkable. … of a pathogen from outside the blood stream) blood cultures are common, leading to falsely positive test … presence of predisposing factors and a consistent clinical presentation can help clinicians interpret test … March 13, 2019 Communicating Critical Test Results. … Topic Clinical Technologists Physicians Pathology and Laboratory Medicine Diagnostic Test

Deficiencies in Care, Care Coordination, and Facility Response to a Patient Who Died by Suicide, Memphis VA Medical Center in Tennessee. | PSNet

psnet.ahrq.gov/issue/deficiencies-care-care-coordination-and-facility-response-patient-who-died-suicide-memphis-va

December 16, 2020 - Deficiencies in Care, Care Coordination, and Facility Response to a Patient Who Died by Suicide, Memphis VA Medical … Haley VA Medical Center, Tampa, Florida. … 2024 Deficiencies in Quality Management Processes and Delays in the Communication of Test … Johnson VA Medical Center in Clarksburg, West Virginia. … Roudebush VA Medical Center in Indianapolis, Indiana.

5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: protocol, methods, and analysis of data. | PSNet

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November 12, 2014 - Endocrinology and American Association of Clinical Endocrinologists position statement on patient safety and medical … November 20, 2015 Impact of interactions between drugs and laboratory test results on … diagnostic test interpretation—a systematic review. … November 21, 2018 Diagnostic error as a result of drug-laboratory test interactions.

Reduction in hospital-wide clinical laboratory specimen identification errors following process interventions: a 10-year retrospective observational study. | PSNet

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August 26, 2011 - More Related Resources Adherence to national guidelines for timeliness of test … Amended Lab Results: Communication Slip February 1, 2012 Medical … Improving follow-up of abnormal cancer screens using electronic health records: trust but verify test … , 2011 Frequency of failure to inform patients of clinically significant outpatient test

2022 Updated Results for the AHRQ Surveys on Patient Safety Culture (SOPS) Diagnostic Safety Supplemental Items. | PSNet

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April 06, 2022 - This survey of over 1,000 clinicians and staff in 110 medical offices examined the extent to which … Key findings demonstrate strengths in specialist consultation and test result communication. … May 2, 2018 Medical Office Survey: 2020 User Database Report. … April 22, 2018 Surveys on Patient Safety Culture (SOPS) Medical Office Survey: 2024 User … August 17, 2022 Surveys on Patient Safety Culture (SOPS) Medical Office Survey: 2022

Care and Oversight Deficiencies Related to Multiple Homicides at the Louis A. Johnson VA Medical Center in Clarksburg, West Virginia. | PSNet

psnet.ahrq.gov/issue/care-and-oversight-deficiencies-related-multiple-homicides-louis-johnson-va-medical-center

February 10, 2021 - Johnson VA Medical Center in Clarksburg, West Virginia. … Johnson VA Medical Center in Clarksburg, West Virginia. … Johnson VA Medical Center in Clarksburg, West Virginia. … Haley VA Medical Center, Tampa, Florida. … May 3, 2023 Multiple Failures in Test Results Follow-up for a Patient Diagnosed with

Adverse drug events in U.S. adult ambulatory medical care. | PSNet

psnet.ahrq.gov/issue/adverse-drug-events-us-adult-ambulatory-medical-care

June 21, 2010 - Classic Adverse drug events in U.S. adult ambulatory medical … Adverse drug events in U.S. adult ambulatory medical care. … Adverse drug events in U.S. adult ambulatory medical care. … , 2010 Frequency of failure to inform patients of clinically significant outpatient test … Hospital ward adaptation during the COVID-19 pandemic: a national survey of academic medical

In Conversation with Elizabeth Salisbury-Afshar about Harm Reduction Strategies to Improve Safety for People Who Use Substances | PSNet

psnet.ahrq.gov/perspective/conversation-elizabeth-salisbury-afshar-about-harm-reduction-strategies-improve-safety

October 30, 2024 - We typically see individuals admitted for another medical indication who, once hospitalized, appear to … lot of local community organizations like syringe service programs, the jail, and other places that test … medical care and medications for addiction treatment if needed. … This strategy can involve distribution of test strips that allow PWUS to test for specific substances … However, the test strips are inexpensive, early studies show the tests are accurate, 19 and PWUS have

Ambulatory Care Safety | PSNet

psnet.ahrq.gov/primer/ambulatory-care-safety

December 15, 2024 - Recent data suggests that timely information availability and managing test results contribute to … the ambulatory setting is ubiquitous, many practices still lack reliable systems for following up on test … empowering patients and caregivers to act as a safety "double-check" by providing access to advice and test … Errors June 15, 2024 Editor's Picks Surveys on Patient Safety Culture (SOPS) Medical … July 6, 2022 Medical Office Survey on Patient Safety Culture.

Investigation of urology intraoperative events leading to root cause analysis at national VA medical centers. | PSNet

psnet.ahrq.gov/issue/investigation-urology-intraoperative-events-leading-root-cause-analysis-national-va-medical

June 02, 2021 - Investigation of urology intraoperative events leading to root cause analysis at national VA medical … Text: Investigation of urology intraoperative events leading to root cause analysis at national VA medical … Text: Investigation of urology intraoperative events leading to root cause analysis at national VA medical … the Same Author(s) Can patients contribute to enhancing the safety and effectiveness of test-result

Making Healthcare Safe: The Story of the Patient Safety Movement. | PSNet

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January 20, 2021 - notable career in safety to outline milestones in the current effort to reduce patient harm due to medical … April 15, 2020 Advances in Human Factors and Ergonomics in Healthcare and Medical Devices … September 11, 2019 Diagnoses Without Names: Challenges for Medical Care, Research, and … October 16, 2023 Communicating Critical Test Results. … August 3, 2020 The Power to Predict: Leveraging Medical Malpractice Data to Reduce Patient

Diagnostic stewardship—leveraging the laboratory to improve antimicrobial use. | PSNet

psnet.ahrq.gov/issue/diagnostic-stewardship-leveraging-laboratory-improve-antimicrobial-use

March 15, 2023 - April 22, 2020 WebM&M Cases Consequences of Medical Overuse … Related Resources Implementing a safer and more reliable system to monitor test … November 1, 2023 Eight recommendations for policies for communicating abnormal test results

Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. | PSNet

psnet.ahrq.gov/issue/systematic-review-impact-health-information-technology-quality-efficiency-and-costs-medical

March 30, 2022 - Systematic review: impact of health information technology on quality, efficiency, and costs of medical … Systematic review: impact of health information technology on quality, efficiency, and costs of medical … Systematic review: impact of health information technology on quality, efficiency, and costs of medical … Deficiencies after the New Electronic Health Record Go-Live at the Mann-Grandstaff VA Medical … November 8, 2017 The safety implications of missed test results for hospitalised patients

VA pauses $16B Oracle Cerner EHR deployments indefinitely to address error-ridden early rollout. | PSNet

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September 14, 2022 - discusses the temporary halt of the project as the Department reassesses issues that have arisen during test … May 31, 2023 Why hospitals still make serious medical errors—and how they are trying … March 15, 2023 Embedded bias: how medical records sow discrimination. … October 5, 2022 When medical error becomes personal, activism becomes painful.

Anemia and Delayed Colon Cancer Diagnosis | PSNet

psnet.ahrq.gov/web-mm/anemia-and-delayed-colon-cancer-diagnosis

July 21, 2020 - A fecal occult blood test was not performed. … Either a fecal occult blood test or a fecal immunochemical test could have been performed to confirm … or other relationship with the manufacturers of any commercial products discussed in this continuing medical … does not include information regarding investigational or off-label use of pharmaceutical products or medical … Fecal occult blood test performance indicators in warfarin-treated patients.

Improving Safety and Security for Veterans Act of 2020. | PSNet

psnet.ahrq.gov/issue/improving-safety-and-security-veterans-act-2020

March 25, 2020 - Veterans Health System by requiring reports on the quality of care and patient safety issues at VA medical … March 25, 2020 Responses of physicians to an objective safety and quality knowledge test … May 14, 2015 The National Medical Error Disclosure and Compensation (MEDiC) Act. … September 10, 2009 An Amendment of the Medical Care Availability and Reduction of Error

Safety gaps in medical team communication: closing the loop on quality improvement efforts in the cardiac catheterization lab. | PSNet

psnet.ahrq.gov/issue/safety-gaps-medical-team-communication-closing-loop-quality-improvement-efforts-cardiac

June 01, 2022 - Study Safety gaps in medical team communication: closing the loop on quality improvement … Safety gaps in medical team communication: closing the loop on quality improvement efforts in the cardiac … Safety gaps in medical team communication: closing the loop on quality improvement efforts in the cardiac … June 1, 2022 Why test results are still getting "lost" to follow-up: a qualitative study … February 2, 2011 Characteristics of medical professional liability claims in patients

Diagnostic Safety Improvement | PSNet

psnet.ahrq.gov/curated-library/diagnostic-safety-improvement

April 17, 2025 - This qualitative study explored how clinicians ensure optimal management of diagnostic test results, … Through a systematic review and observations of team dynamics in a hospital medical ward, researchers … In this retrospective study, researchers analyzed patient complaint and medical record data and found … manual processes, cognitive reminders, and adaptive use of electronic medical record functionality. … and involve a wide range of professionals, including pathologists, allied health practitioners, and medical

Analysis of clinical decision support system malfunctions: a case series and survey. | PSNet

psnet.ahrq.gov/issue/analysis-clinical-decision-support-system-malfunctions-case-series-and-survey

April 29, 2018 - Investigators analyzed clinical decision support system malfunctions and surveyed chief medical informatics … May 20, 2019 The need for closed-loop systems for management of abnormal test results … July 2, 2019 Understanding test results follow-up in the ambulatory setting: analysis

Efficiency and interpretability of text paging communication for medical inpatients: a mixed-methods analysis. | PSNet

psnet.ahrq.gov/issue/efficiency-and-interpretability-text-paging-communication-medical-inpatients-mixed-methods

August 09, 2023 - Study Efficiency and interpretability of text paging communication for medical inpatients … Author(s) Experimental evidence for structured information-sharing networks reducing medical … September 7, 2016 An initiative to improve the management of clinically significant test

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