AHRQ Patient Safety Network

The Collection > Pathology & Laboratory Medicine

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Safety Target

•Device-related Complications (1)

•Diagnostic Errors (41)

•Identification Errors (29)

•Discontinuities, Gaps, and Hand-Off Problems (29)

•Medication Safety (7)

•Medical Complications (4)

•Nonsurgical Procedural Complications (1)

•Surgical Complications (5)

•Transfusion Complications (9)

•Psychological and Social Complications (7)

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•Asia (4)

•Australia and New Zealand (2)

•Central and South America (2)

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•North America (81)

Resource Types

•Book/Report (2)

•Journal Article (91)

•Legislation/Regulation (1)

•Meeting/Conference (1)

•Newspaper/Magazine Article (5)

•Special or Theme Issue (2)

•Tools/Toolkit (1)

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Error Types

•Epidemiology of Errors and Adverse Events (29)

•Active Errors (35)

•Latent Errors (14)

•Near Miss (2)

Approach to Improving Safety

•Quality Improvement Strategies (37)

•Legal and Policy Approaches (6)

•Error Reporting and Analysis (35)

•Communication Improvement (21)

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•Logistical Approaches (28)

•Culture of Safety (5)

•Technologic Approaches (25)

•Education and Training (9)

Clinical Areas
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Pathology & Laboratory Medicine

Target Audience

•Health Care Providers (90)

•Health Care Executives and Administrators (76)

•Non-Health Care Professionals (25)

•Patients (3)

Setting of Care

•Hospitals (31)

•Ambulatory Care (12)

•Outpatient Surgery (1)

1 - 20 of 104

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STUDY

Patient misidentification in laboratory medicine: a qualitative analysis of 227 root cause analysis reports in the Veterans Health Administration.

Dunn EJ, Moga PJ. Arch Pathol Lab Med. 2010;134:244-255.

STUDY

Specimen labeling errors in surgical pathology: an 18-month experience.

Layfield LJ, Anderson GM. Am J Clin Pathol. 2010;134:466-470.

STUDY

Decreasing mislabeled laboratory specimens using barcode technology and bedside printers.

Brown JE, Smith N, Sherfy BR. J Nurs Care Qual. 2011;26:13-21.

COMMENTARY

Transfusion "Slip".

Kaplan HS. AHRQ WebM&M [serial online]. February 2004.

STUDY

Mislabeled units of umbilical cord blood detected by a quality assurance program at the transplantation center.

McCullough J, McKenna D, Kadidlo D, et al. Blood. 2009:114:1684-1688.

STUDY

The Henry Ford Production System: reduction of surgical pathology in-process misidentification defects by bar code-specified work process standardization.

Zarbo RJ, Tuthill JM, D'Angelo R, et al. Am J Clin Pathol. 2009;131:468-477.

REVIEW

Barcode identification for transfusion safety.

Murphy MF, Kay JD. Curr Opin Hematol. 2004;11:334-338.

STUDY

Clinical staging error in prostate cancer: localization and relevance of undetected tumour areas.

Bolenz C, Gierth M, Grobholz R, et al. BJU Int. 2009;103:1184-1189.

STUDY

Quality improvement to decrease specimen mislabeling in transfusion medicine.

Quillen K, Murphy K. Arch Pathol Lab Med. 2006;130:1196-1198.

REVIEW

Quality in cancer diagnosis.

Raab SS, Grzybicki DM. CA Cancer J Clin. 2010;60:139-165.

STUDY

Tracking with virtual slides: a tool to study diagnostic error in histopathology.

Treanor D, Lim CH, Magee D, Bulpitt A, Quirke P. Histopathology. 2009;55:37-45.

STUDY

Current and emerging infectious risks of blood transfusions.

Busch MP, Kleinman SH, Nemo GJ. JAMA. 2003;289:959-962.

NEWSPAPER/MAGAZINE ARTICLE

Lost surgical specimens, lost opportunities.

PA-PSRS Patient Saf Advis. September 2005;2:1-5.

SPECIAL OR THEME ISSUE

Errors in Laboratory Medicine and Patient Safety.

Plebani M, ed. Clinica Chimica Acta. 2009;404(1):1-86.

REVIEW

Causes, consequences, detection, and prevention of identification errors in laboratory diagnostics.

Lippi G, Blanckaert N, Bonini P, et al. Clin Chem Lab Med. 2009;47:143-153.

STUDY

Real-time clinical alerting: effect of an automated paging system on response time to critical laboratory values—a randomised controlled trial.

Etchells E, Adhikari NKJ, Cheung C, et al. Qual Saf Health Care. 2010;19:99-102.

COMMENTARY

EMR Entry Error: Not So Benign

Koppel R. AHRQ WebM&M [serial online]. April 2009.

COMMENTARY

Quality indicators to detect pre-analytical errors in laboratory testing.

Plebani M. Clin Biochem Rev. 2012;33:85-88.

COMMENTARY

No Blood, Please.

Liang BA. AHRQ WebM&M [serial online]. May 2004.

STUDY

Is the test result correct? A questionnaire study of blood collection practices in primary health care.

Söderberg J, Wallin O, Grankvist K, Brulin C. J Eval Clin Pract. 2010;16:707-711.

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