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Showing results for "sample".

41. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/50949/psn-pdf
    February 26, 2020 - Both the central laboratory and satellite facility were not aware that the sample was missing until … 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 … In Case #1, if the microbiology sample were to have been positive, resulting delays in the treatment … For example, an incorrect labeled fine needle aspirate sample can lead to inappropriate treatment for

42. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/74077/psn-pdf
    November 17, 2021 - factors-associated-wrong-blood-tube-errors-international-case-series-best-collaborative-study https://psnet.ahrq.gov/web-mm/right-patient-wrong-sample … https://psnet.ahrq.gov/issue/electronic-patient-identification-sample-labeling-reduces-wrong-blood-tube-errors

43. Spotlight
    psnet.ahrq.gov/sites/default/files/2024-08/spotlight_case_a_fatal_twist_in_pseudohyperkalemia_slides.pptx
    January 01, 2024 - 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. Diagnosis (Berl). 2019;6(1):25-31. … The Impact of Undetected In Vitro Hemolysis or Sample Contamination on Patient Care and Outcomes in Point-of-Care

44. 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

45. Urine a Tough Position | PSNet
    psnet.ahrq.gov/web-mm/urine-tough-position
    January 01, 2009 - The patient collected her own urine sample and placed it in the specimen cabinet, which opens into the … The other urine sample belonged to a diabetic patient; the technologist suspected a mix-up after a urine … dipstick on that sample indicated elevated glucose. … Sample labels are often handwritten with minimal information (eg, "Smith" when there could be multiple … In addition, specimen collection bottles should be labeled before the patient provides the sample.

46. Sins of omission. Getting too little medical care may be the greatest threat to patient safety. | PSNet
    psnet.ahrq.gov/issue/sins-omission-getting-too-little-medical-care-may-be-greatest-threat-patient-safety
    March 06, 2005 - Using a random sample of more than 600 patients from a Veterans Affairs health care system, investigators … Comparison of quality of care for patients in the Veterans Health Administration and patients in a national sample

47. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/45900/psn-pdf
    June 07, 2017 - An error associated with a mislabeled blood sample is discussed in a past WebM&M commentary. … computer-assisted-bar-coding-system-significantly-reduces-clinical-laboratory-specimen https://psnet.ahrq.gov/web-mm/right-patient-wrong-sample

48. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/50841/psn-pdf
    January 29, 2020 - 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.

49. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/865336/psn-pdf
    March 27, 2024 - Most reported errors were near misses and occurred during sample collection, sample handling, and product

50. Negligent care and malpractice claiming behavior in Utah and Colorado. | PSNet
    psnet.ahrq.gov/issue/negligent-care-and-malpractice-claiming-behavior-utah-and-colorado
    June 23, 2015 - medical liability claims in a review of 15,000 hospital discharges in Utah and Colorado in 1992, a sample … Of the 18 malpractice claims in the sample, 14 were made in the absence of any negligence.

51. Blood bank specimen mislabeling: a College of American Pathologists Q-Probes study of 41,333 blood bank specimens in 30 institutions. | PSNet
    psnet.ahrq.gov/issue/blood-bank-specimen-mislabeling-college-american-pathologists-q-probes-study-41333-blood-bank
    November 16, 2022 - An error associated with a mislabeled blood sample is discussed in a past WebM&M commentary .

52. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/43122/psn-pdf
    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

53. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/866618/psn-pdf
    December 31, 2024 - 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. Diagnosis (Berl). 2019;6(1):25-31. [ Free full text] 3. … The Impact of Undetected In Vitro Hemolysis or Sample Contamination on Patient Care and Outcomes in

54. A 2-year study of patient safety competency assessment in 29 clinical laboratories. | PSNet
    psnet.ahrq.gov/issue/2-year-study-patient-safety-competency-assessment-29-clinical-laboratories
    December 14, 2016 - August 20, 2018 WebM&M Cases Right Patient, Wrong Sample … of Texas System Clinical Safety and Effectiveness Course February 1, 2011 Sample … to sample carryover: a source of analytical laboratory error and its relevance to integrated clinical

55. 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

56. “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.

57. 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

58. 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

59. Preanalytical errors in primary healthcare: a questionnaire study of information search procedures, test request management and test tube labelling. | PSNet
    psnet.ahrq.gov/issue/preanalytical-errors-primary-healthcare-questionnaire-study-information-search-procedures
    July 07, 2010 - Most errors in laboratory medicine occur in the preanalytical phase, that is, before the sample reaches

60. Psn-Pdf (pdf file)
    psnet.ahrq.gov/node/38418/psn-pdf
    February 18, 2009 - Using snowball sampling method with nurses to understand medication administration errors. February 18, 2009 Sheu S-J, Wei I-L, Chen C-H, et al. Using snowball sampling method with nurses to understand medication administration errors. J Clin Nurs. 2009;18(4):559-69. doi:10.1111/j.1365-2702.2007.02048.x. https://p…