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Total Results: 231 records

Showing results for "sample".

1. Right Patient, Wrong Sample | PSNet
   psnet.ahrq.gov/web-mm/right-patient-wrong-sample
   June 01, 2004 - Right Patient, Wrong Sample Citation Text: Astion ML. Right Patient, Wrong Sample. … Right Patient, Wrong Sample. PSNet [internet]. … The sample was sent to the laboratory for analysis. … morning, a laboratory technician noticed a large and surprising change (compared to the previous day’s sample … Right Patient, Wrong Sample. PSNet [internet].

2. The July effect: an analysis of never events in the nationwide inpatient sample. | PSNet
   psnet.ahrq.gov/issue/july-effect-analysis-never-events-nationwide-inpatient-sample
   November 04, 2020 - Classic The July effect: an analysis of never events in the nationwide inpatient sample … The July effect: an analysis of never events in the nationwide inpatient sample. … This retrospective cohort study used the AHRQ-maintained nationwide inpatient sample database to examine … The July effect: an analysis of never events in the nationwide inpatient sample.

3. Transfusion-related errors and associated adverse reactions and blood product wastage as reported to the National Healthcare Safety Network Hemovigilance Module, 2014-2022. | PSNet
   psnet.ahrq.gov/issue/transfusion-related-errors-and-associated-adverse-reactions-and-blood-product-wastage
   September 23, 2020 - Most reported errors were near misses and occurred during sample collection, sample handling, and product … April 12, 2011 Enhanced detection of blood bank sample collection errors with a centralized

4. Psn-Pdf (pdf file)
   psnet.ahrq.gov/node/43342/psn-pdf
   July 16, 2014 - Prevalence and severity of patient harm in a sample of UK-hospitalised children detected by the Paediatric … Prevalence and severity of patient harm in a sample of UK- hospitalised children detected by the Paediatric … https://psnet.ahrq.gov/issue/prevalence-and-severity-patient-harm-sample-uk-hospitalised-children- detected-paediatric … https://psnet.ahrq.gov/issue/prevalence-and-severity-patient-harm-sample-uk-hospitalised-children-detected-paediatric … https://psnet.ahrq.gov/issue/prevalence-and-severity-patient-harm-sample-uk-hospitalised-children-detected-paediatric

5. Electronic patient identification for sample labeling reduces wrong blood in tube errors. | PSNet
   psnet.ahrq.gov/issue/electronic-patient-identification-sample-labeling-reduces-wrong-blood-tube-errors
   September 20, 2012 - Emerging Classic Electronic patient identification for sample … Electronic patient identification for sample labeling reduces wrong blood in tube errors. … Electronic patient identification for sample labeling reduces wrong blood in tube errors.

6. Prevalence and severity of patient harm in a sample of UK-hospitalised children detected by the Paediatric Trigger Tool. | PSNet
   psnet.ahrq.gov/issue/prevalence-and-severity-patient-harm-sample-uk-hospitalised-children-detected-paediatric
   February 15, 2023 - Study Prevalence and severity of patient harm in a sample of UK-hospitalised children … Prevalence and severity of patient harm in a sample of UK-hospitalised children detected by the Paediatric … Prevalence and severity of patient harm in a sample of UK-hospitalised children detected by the Paediatric

7. Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based sample. | PSNet
   psnet.ahrq.gov/issue/missed-diagnosis-stroke-emergency-department-cross-sectional-analysis-large-population-based
   April 08, 2018 - diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based sample … diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based sample … diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based sample

8. National incidence of medication error in surgical patients before and after Accreditation Council for Graduate Medical Education duty-hour reform. | PSNet
   psnet.ahrq.gov/issue/national-incidence-medication-error-surgical-patients-and-after-accreditation-council
   September 23, 2020 - Using the Nationwide Inpatient Sample, a representative sample of hospitalizations maintained by AHRQ's

9. “This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event | PSNet
   psnet.ahrq.gov/web-mm/wrong-patients-blood-evaluating-near-miss-wrong-transfusion-event
   July 01, 2017 - At our institution, an initial blood sample is sent in a purple tube from the holding area and then the … blood bank will request a second confirmatory sample in a pink tube. … During this time, the patient's pink tube for the confirmatory blood sample was delivered to the room … The blood bank was notified, the blood returned, and a new blood sample sent. … collection should ensure the wristband and sample label match.

10. Pre-analytical pitfalls: Missing and mislabeled specimens | PSNet
    psnet.ahrq.gov/web-mm/pre-analytical-pitfalls-missing-and-mislabeled-specimens
    April 18, 2018 - Both the central laboratory and satellite facility were not aware that the sample was missing until the … The ordering physician was notified of the missing sample. … Follow-up investigation by the ED ultimately revealed the initial sample with the high cardiac troponin … The incorrect patient label was placed on the cardiac troponin I sample, which resulted in the report … In Case #1, if the microbiology sample were to have been positive, resulting delays in the treatment

11. Hemolysis Holdup | PSNet
    psnet.ahrq.gov/web-mm/hemolysis-holdup
    July 03, 2016 - However, the laboratory noted that the patient's blood sample was hemolyzed, which can spuriously increase … Effective practices to reduce blood sample hemolysis in emergency departments. [Available at] 7. … Effectiveness of practices to reduce blood sample hemolysis in EDs: a laboratory medicine best practices

12. A Fatal Twist in Pseudohyperkalemia | PSNet
    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 … phlebotomy staff should be counseled on proper techniques to reduce in vitro hemolysis during and after sample … Alternatively, a new sample should be collected. … Blood sample quality. … The Impact of Undetected In Vitro Hemolysis or Sample Contamination on Patient Care and Outcomes in Point-of-Care

13. A Postpartum Woman with an Erroneous SARS-CoV-2 Test | PSNet
    psnet.ahrq.gov/web-mm/postpartum-woman-erroneous-sars-cov-2-test
    December 23, 2020 - However, due to delays in receiving those results, another sample was tested two days later with a newly … developed in-house test and a third sample was sent to the state public health laboratory. … positive test run on the in-house platform was due to cross-contamination from a neighboring positive sample … A follow-up test conducted on a remnant sample from the in-house assay, one week later, confirmed that

14. What Every Health Care Organization Should Know about Sentinel Events. | PSNet
    psnet.ahrq.gov/issue/what-every-health-care-organization-should-know-about-sentinel-events
    November 27, 2018 - The text includes a sample sentinel event root cause analysis form and a glossary.

15. Burnout, engagement, and dental errors among U.S. dentists. | PSNet
    psnet.ahrq.gov/issue/burnout-engagement-and-dental-errors-among-us-dentists
    October 28, 2020 - This survey of a national sample of dentists found that approximately 1 in 10 respondents reported high

16. Patient identification and tube labelling—a call for harmonisation. | PSNet
    psnet.ahrq.gov/issue/patient-identification-and-tube-labelling-call-harmonisation
    April 29, 2020 - for standardizing the processes involved in phlebotomy to reduce the potential for both patient and sample

17. Predictors of nursing home nurses' willingness to report medication near-misses. | PSNet
    psnet.ahrq.gov/issue/predictors-nursing-home-nurses-willingness-report-medication-near-misses
    July 31, 2024 - Using a random sample of 500 nursing home nurses in one state, this study tested a proposed predictive

18. Healthcare Safety for Nursing Personnel: An Organizational Guide to Achieving Results. | PSNet
    psnet.ahrq.gov/issue/healthcare-safety-nursing-personnel-organizational-guide-achieving-results
    February 11, 2015 - Helpful resources such as checklists , sample control plans, and review exercises are also included.

19. Medication Reconciliation Handbook, 2nd edition. | PSNet
    psnet.ahrq.gov/issue/medication-reconciliation-handbook-2nd-edition
    May 04, 2015 - provides background on the medication reconciliation  process and tips for its application, along with sample

20. Risk of medication errors and nurses' quality of sleep: a national cross-sectional web survey study. | PSNet
    psnet.ahrq.gov/issue/risk-medication-errors-and-nurses-quality-sleep-national-cross-sectional-web-survey-study
    February 09, 2022 - Based on survey data of a sample of nurses, the authors identified a significant association between