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361. Spotlight Case July 2008 (ppt file)
     psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.290_slideshow.ppt
     February 01, 2013 - Particularly difficult after patient has left ED or inpatient unit In one study of three particular tests … basis * * Suggested Steps Engage patients in following up on test results Educate them about tests … failure to contact patients about abnormal test results are engaging patients in following up on pending tests

362. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/49509/psn-pdf
     April 01, 2006 - These inexpensive tests are sensitive to 20 mIU/mL of HCG, a level typical of pregnancies at about the … To avoid IUC insertion during pregnancy, performing sensitive, rapid urine pregnancy tests and waiting … Testing women for chlamydia with rapid amplified DNA tests can reduce this risk, since https://psnet.ahrq.gov

363. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/867980/psn-pdf
     March 25, 2025 - In most cases, there are no definitive tests to determine a specific etiology for a patient’s headache … pursue further diagnostic evaluation, including imaging, applicable laboratory testing, and other tests … However, pursuing such tests in most patients with headache is unnecessary, leading to excessive testing

364. Diagnostic Errors Case Studies | PSNet
     psnet.ahrq.gov/curated-library/diagnostic-errors-case-studies
     May 05, 2025 - Two days after the patient’s discharge, the commercial and state lab tests were both reported as negative … testing, the unprecedented burden faced by health systems, and downstream consequences of false positive tests … The patient elected not to follow up with the tests because of this negative interaction.

365. Finding blunders in thyroid testing: experience in newborns. | PSNet
     psnet.ahrq.gov/issue/finding-blunders-thyroid-testing-experience-newborns
     March 04, 2020 - Inconsistent and possibly erroneous results of thyroid tests for newborns occurred in 18 patients among

366. Clinician factors associated with delayed diagnosis of appendicitis. | PSNet
     psnet.ahrq.gov/issue/clinician-factors-associated-delayed-diagnosis-appendicitis
     October 26, 2022 - appendicitis found that delayed diagnosis occurred in 1.4% of cases and increased clinician use of blood tests

367. Swiss Cheese Model | PSNet
     psnet.ahrq.gov/taxonomy/term/3460
     January 20, 2025 - wrong-site surgery, slices of the cheese might include conventions for identifying sidedness on radiology tests

368. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/36334/psn-pdf
     October 26, 2010 - As in the outpatient arena, errors generally occurred due to failure to order diagnostic tests or interpret

369. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41101/psn-pdf
     October 16, 2012 - provider–patient interaction (e.g., missing important symptoms); diagnostic testing (e.g., overuse or underuse of tests

370. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45575/psn-pdf
     November 09, 2016 - projects undertaken demonstrated success in reducing the unneeded intervention: fewer serum creatinine tests

371. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40925/psn-pdf
     December 07, 2011 - included arranging follow-up appointments, performing medication reconciliation, and following up on tests

372. Coronavirus Disease 2019 (COVID-19) and Safety of Older Adults Residing in Nursing Homes | PSNet
     psnet.ahrq.gov/primer/coronavirus-disease-2019-covid-19-and-safety-older-adults
     April 10, 2024 - For example, the rapid tests only have an 80% sensitivity, and some states require higher sensitivity … manufacturers with Food and Drug Administration (FDA) approval had stated that their rapid antigen tests … CDC provided additional training resources to help with training staff to perform point-of-care tests … Trump administration to mandate Covid-19 tests for nursing-home staff. Wall Street Journal.   … Trump is sending fast, cheap COVID tests to nursing homes— but there’s a hitch.

373. UTMC nurse tossed out kidney, ruined it. National experts say error is rare. | PSNet
     psnet.ahrq.gov/issue/utmc-nurse-tossed-out-kidney-ruined-it-national-experts-say-error-rare
     August 07, 2024 - May 27, 2011 How one medical checkup can snowball into a ‘cascade’ of tests, causing

374. Utility of clinical examination in the diagnosis of emergency department patients admitted to the department of medicine of an academic hospital. | PSNet
     psnet.ahrq.gov/issue/utility-clinical-examination-diagnosis-emergency-department-patients-admitted-department
     April 06, 2022 - correctly diagnosed from information gleaned by the history, physical examination, and basic laboratory tests

375. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/38621/psn-pdf
     February 18, 2011 - providers for failing to perform adequate physical exams and patients for failing to undergo recommended tests

376. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/40932/psn-pdf
     July 05, 2016 - health-it-and-patient-safety-building-safer-systems-better-care https://psnet.ahrq.gov/issue/lessons-learned-implementation-computerized-application-pending-tests-hospital-discharge

377. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/45437/psn-pdf
     September 01, 2018 - promoting the practice of defensive medicine—which can lead to adverse events through unnecessary tests

378. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/41413/psn-pdf
     September 26, 2012 - Communication of posthospital care, including tests pending at discharge, is a critical element of effective

379. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/39986/psn-pdf
     November 10, 2010 - corroborates other studies documenting persistent failure to comprehensively follow up abnormal lab tests

380. Psn-Pdf (pdf file)
     psnet.ahrq.gov/node/43911/psn-pdf
     April 15, 2016 - psnet.ahrq.gov/primer/ambulatory-care-safety https://psnet.ahrq.gov/issue/older-patients-perceptions-unnecessary-tests-and-referrals-national-survey-medicare