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psnet.ahrq.gov/node/49421/psn-pdf
October 01, 2003 - 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 … However, before a printed label is affixed to a sample, confirmation with the patient is still
necessary
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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
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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
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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
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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.
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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
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psnet.ahrq.gov/node/38372/psn-pdf
April 09, 2009 - This study found that sample medications lacked instructions that could be understood by
patients with
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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.
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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
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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
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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
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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
-
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
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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
-
psnet.ahrq.gov/node/34704/psn-pdf
December 24, 2008 - 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.
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psnet.ahrq.gov/issue/quality-improvement-decrease-specimen-mislabeling-transfusion-medicine
September 11, 2024 - September 29, 2021
Electronic patient identification for sample labeling reduces wrong … December 24, 2008
WebM&M Cases
Right Patient, Wrong Sample
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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
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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.
-
psnet.ahrq.gov/node/44305/psn-pdf
January 22, 2016 - Using the Nationwide Inpatient Sample, a representative sample of hospitalizations
maintained by AHRQ's
-
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