-
psnet.ahrq.gov/node/47285/psn-pdf
November 19, 2018 - They recommend inclusion of sociodemographic characteristics into algorithms, building and
testing algorithms … in diverse health care systems, and conducting follow-up testing to ensure that machine
learning does
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psnet.ahrq.gov/issue/barriers-and-motivators-making-error-reports-family-medicine-offices-report-american-academy
July 14, 2010 - July 14, 2010
Mitigation of patient harm from testing errors in family medicine offices … June 11, 2008
Testing process errors and their harms and consequences reported from family … October 4, 2023
Laboratory testing in general practice: a patient safety blind spot.
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psnet.ahrq.gov/node/49527/psn-pdf
December 01, 2006 - Clinical impact associated with corrected results in clinical
microbiology testing. … Errors and patient outcomes associated with
problems in stat chemistry testing. … Major software enhancements
Implementing computerized physician order entry for lab
testing. … Standardize equipment or processes
Use one brand of glucometer at all point-of-care testing
locations … New device with usability testing
before purchasing
New analyzer for autoantibody testing removes several
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psnet.ahrq.gov/node/45797/psn-pdf
October 31, 2017 - history, incomplete
physical examination performance or documentation, and lack of needed laboratory testing … Consistent with
prior studies, failure to order laboratory testing and plan follow-up were associated
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psnet.ahrq.gov/node/39266/psn-pdf
March 05, 2010 - effects-stress-and-coping-surgical-performance-during-simulations
https://psnet.ahrq.gov/issue/surgeons-non-technical-skills-operating-room-reliability-testing-notss-behavior-rating-system … https://psnet.ahrq.gov/issue/surgeons-non-technical-skills-operating-room-reliability-testing-notss-behavior-rating-system
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psnet.ahrq.gov/node/49490/psn-pdf
September 01, 2005 - Ginsburg also applied heuristic evaluation and HFE usability testing to three infusion pumps.(9) In usability … testing, 17 typical infusion pump users attempted several realistic clinical scenarios on 3 infusion … to industry their commitment to HFE aspects of design.(13) Other hospitals
are employing usability testing … in HFE principles,
can detect and suggest fixes for many potential vulnerabilities.(14) Usability testing … Usability testing can also guide the focus and content of in-service
training on infusion pumps.
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psnet.ahrq.gov/issue/medical-overuse-physician-cognitive-error-looking-under-hood
September 25, 2019 - 2019
Accuracy of practitioner estimates of probability of diagnosis before and after testing … 2021
Accuracy of practitioner estimates of probability of diagnosis before and after testing
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psnet.ahrq.gov/issue/medical-errors-arising-outsourcing-laboratory-and-radiology-services
October 19, 2022 - Resources
Measuring the rate of manual transcription error in outpatient point-of-care testing … February 15, 2010
Finding blunders in thyroid testing: experience in newborns.
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psnet.ahrq.gov/issue/improving-pathologists-communication-skills
May 18, 2022 - July 27, 2016
When diagnostic testing leads to harm: a new outcomes-based approach for … September 26, 2012
Quality indicators to detect pre-analytical errors in laboratory testing
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psnet.ahrq.gov/issue/sorry-works-coalition-making-case-full-disclosure
May 18, 2022 - April 27, 2022
Alcohol and drug testing of health professionals following preventable … July 2, 2009
Dissemination of Lean methods to improve Pap testing quality and patient
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psnet.ahrq.gov/web-mm/consequences-medical-overuse
May 05, 2021 - Another reason is that troponin is often included in routine workups or screening testing in the emergency … All of these indications for troponin testing are inappropriate and represent a form of medical overuse … or more of these tests would have detected an incidental abnormality, which would have led to more testing … Use of cardiac biomarker testing in the emergency department. JAMA Intern Med. 2015;175:67-75. … Troponin testing in the emergency setting: how good are we?
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psnet.ahrq.gov/web-mm/fatal-twist-pseudohyperkalemia
February 10, 2021 - Clinicians should have a low threshold to repeat diagnostic testing such as routine bloodwork and 12- … lead ECG, particularly when the risks of testing are minimal relative to the risks of misdiagnosis and … If hemolysis is detected, clinical laboratory workflows should exist to automatically prompt repeat testing … Undetected In Vitro Hemolysis or Sample Contamination on Patient Care and Outcomes in Point-of-Care Testing … Educational case: hemolysis and lipemia interference with laboratory testing.
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psnet.ahrq.gov/issue/developing-and-testing-tool-measure-nursephysician-communication-intensive-care-unit
June 01, 2011 - Study
Developing and testing a tool to measure nurse/physician communication in the
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psnet.ahrq.gov/web-mm/pathologic-mistake
February 15, 2010 - as reactive lymph nodes and lymphomas.( 1-4 ) Anatomic pathology is prone to error because the testing … severity scale based on several factors such as morbidity, mortality, delay in diagnosis, and additional testing … severity is generally mild or minimal (depending on the classification system) and results in additional testing … Take-Home Points Anatomic pathology is prone to error at many steps due to the complex nature of the testing … September 1, 2012
Dissemination of Lean methods to improve Pap testing quality and patient
-
psnet.ahrq.gov/issue/trend-analysis-radiation-therapy-incidents-over-seven-years
December 20, 2023 - August 15, 2016
Pilot Testing Fall TIPS (Tailoring Interventions for Patient Safety): … December 22, 2010
Commission of Inquiry on Hormone Receptor Testing.
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psnet.ahrq.gov/node/867004/psn-pdf
October 30, 2024 - Innovation Snapshot
When a patient presents to the emergency department (ED) and receives radiologic testing … , the testing can
identify unrelated abnormal findings1 Unfortunately, this information is often not … of this innovation
are as follows:
A healthcare professional who assists patients with follow-up testing … needed as there are frequent needs to review the radiologist’s
interpretation for recommended follow-up testing
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psnet.ahrq.gov/web-mm/timely-diagnosis-esophageal-perforation
September 27, 2023 - take many forms, many experts agree that effective diagnosticians are good at “iterative hypothesis testing … diagnoses. 5 Systematic pressures in modern inpatient care may detract from using iterative hypothesis testing … unexplained hydropneumothorax in a systemically ill patient should prompt urgent evaluation by a surgeon and testing … Gathering accurate information, forming thoughtful differential diagnoses, and iteratively testing hypothetical … Teaching clinical medicine by iterative hypothesis testing. Let's preach what we practice.
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psnet.ahrq.gov/node/49812/psn-pdf
November 01, 2017 - Preanalytic error, as occurred in this case, typically involves the steps of laboratory testing
that … When easily
retrievable specimens such as blood or a gastrointestinal mucosal biopsy are lost, repeat testing … well-meaning personnel.(4)
Given the inherent complexity and risk associated with the laboratory ordering and testing … Additional, standard communication
between the laboratory and the primary clinical team to clarify testing … Adverse Events Reported by Testing Phase (n, %), Out of a Sample of 1797 Adverse Events.
-
psnet.ahrq.gov/sites/default/files/2020-04/spotlight-slides-wright-schiff.pdf
January 01, 2020 - providers
don't have to enter them themselves
Recommendations for Safe Prescribing (2)
18
• Improve testing … of CPOE to
pharmacy system linkages,
including end-to-end testing
where orders are written in
a … indication-based ordering (that
would allow tailoring orders to different clinical
indications) and better testing
-
psnet.ahrq.gov/issue/diagnostic-error-medicine-analysis-583-physician-reported-errors
June 24, 2009 - pulmonary embolism and drug reactions or overdose, with the errors occurring most frequently in the testing … February 27, 2014
The landscape of inappropriate laboratory testing: a 15-year meta-analysis