AHRQ Patient Safety Network

The Collection > Pathology & Laboratory Medicine

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Safety Target

•Device-related Complications (1)

•Diagnostic Errors (39)

•Identification Errors (25)

•Discontinuities, Gaps, and Hand-Off Problems (25)

•Medication Safety (9)

•Medical Complications (4)

•Nonsurgical Procedural Complications (1)

•Surgical Complications (4)

•Transfusion Complications (8)

•Psychological and Social Complications (6)

Origin/Sponsor

•Asia (5)

•Australia and New Zealand (3)

•Central and South America (2)

•Europe (15)

•North America (68)

Resource Types

•Book/Report (3)

•Journal Article (81)

•Legislation/Regulation (1)

•Meeting/Conference (2)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (3)

•Special or Theme Issue (2)

•Tools/Toolkit (1)

Error Types

•Epidemiology of Errors and Adverse Events (24)

•Active Errors (32)

•Latent Errors (14)

•Near Miss (2)

Approach to Improving Safety

•Quality Improvement Strategies (40)

•Legal and Policy Approaches (6)

•Error Reporting and Analysis (30)

•Communication Improvement (16)

•Human Factors Engineering (12)

•Teamwork (1)

•Specialization of Care (1)

•Logistical Approaches (25)

•Culture of Safety (4)

•Technologic Approaches (26)

•Education and Training (8)

Clinical Areas
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Pathology & Laboratory Medicine

Target Audience

•Health Care Providers (84)

•Health Care Executives and Administrators (64)

•Non-Health Care Professionals (25)

•Patients (2)

Setting of Care

•Hospitals (25)

•Ambulatory Care (12)

1 - 20 of 94

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COMMENTARY

EMR Entry Error: Not So Benign

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

REVIEW

The impact of declining clinical autopsy: need for revised healthcare policy.

Xiao J, Krueger GR, Buja LM, Covinsky M. Am J Med Sci. 2009;337:41-46.

STUDY

Medical malpractice as reflected by the forensic evaluation of 4450 autopsies.

Madea B, Preuß J. Forensic Sci Int. 2009;190:58-66.

BOOK/REPORT

Commission of Inquiry on Hormone Receptor Testing.

Cameron M. St. John's, NL: Government of Newfoundland and Labrador; 2009. ISBN: 978551463537.

REVIEW

Impact of health information technology interventions to improve medication laboratory monitoring for ambulatory patients: a systematic review.

Fischer SH, Tjia J, Field TS. J Am Med Inform Assoc. 2010;17:631-636.

STUDY

Improving follow-up of abnormal cancer screens using electronic health records: trust but verify test result communication.

Singh H, Wilson L, Petersen LA, et al. BMC Med Inform Decis Mak. 2009;9:49.

STUDY

Assessment of quality of data provided on Pap test requisitions: implications for quality of care and patient safety.

Naryshkin S, Schultz BL. Cytojournal. 2009;6:11.

NEWSPAPER/MAGAZINE ARTICLE

Hospitals move to cut dangerous lab errors.

Landro L. Wall Street Journal (Eastern edition). June 14, 2006:D1. [Reprinted on Post-gazette.com].

COMMENTARY

Beyond the prescription: medication monitoring and adverse drug events in older adults.

Steinman MA, Handler SM, Gurwitz JH, Schiff GD, Covinsky KE. J Am Geriatr Soc. 2011;59:1513-1520.

STUDY

Assessment of latent factors contributing to error: addressing surgical pathology error wisely.

Smith ML, Raab SS. Arch Pathol Lab Med. 2011;135:1436-1440.

COMMENTARY

Overriding Considerations.

Holtzman, NA. AHRQ WebM&M [serial online]. December 2004.

STUDY

Laboratory safety monitoring of chronic medications in ambulatory care settings.

Hurley JS, Roberts M, Solberg LI, et al. J Gen Intern Med. 2005;20:331-333.

STUDY

Efficacy of an incident-reporting system in cellular pathology: a practical experience.

Rakha EA, Clark D, Chohan BS, et al. J Clin Pathol. 2012;65:643-648.

COMMENTARY

Consensus statement on effective communication of urgent diagnoses and significant, unexpected diagnoses in surgical pathology and cytopathology from the College of American Pathologists and Association of Directors of Anatomic and Surgical Pathology.

Nakhleh RE, Myer JL, Allen TC, et al. Arch Pathol Lab Med. 2012;136:148-154.

STUDY

Incident reporting practices in the preanalytical phase: low reported frequencies in the primary health care setting.

Söderberg J, Grankvist K, Brulin C, Wallin O. Scand J Clin Lab Invest. 2009;69:731-735.

STUDY

Patient misidentification in Papanicolaou tests: a systems-based approach to reducing errors.

Meyer E, Underwood RS, Padmanabhan V. Arch Pathol Lab Med. 2009;133:1297-1300.

STUDY

Mislabeling of cases, specimens, blocks, and slides: a College of American Pathologists study of 136 institutions.

Nakhleh RE, Idowu MO, Souers RJ, Meier FA, Bekeris LG. Arch Pathol Lab Med. 2011;135:969-974.

COMMENTARY

The Result Stopped Here.

Astion M. AHRQ WebM&M [serial online]. June 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

Frequency of failure to inform patients of clinically significant outpatient test results.

Casalino LP, Dunham D, Chin MH, et al. Arch Intern Med. 2009;169:1123-1129.

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