AHRQ Patient Safety Network

The Collection > Pathology & Laboratory Medicine

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Safety Target

•Device-related Complications (1)

•Diagnostic Errors (51)

•Identification Errors (34)

•Discontinuities, Gaps, and Hand-Off Problems (45)

•Medication Safety (13)

•Medical Complications (3)

•Surgical Complications (5)

•Transfusion Complications (9)

•Psychological and Social Complications (5)

Origin/Sponsor

•Asia (4)

•Australia and New Zealand (3)

•Central and South America (1)

•Europe (16)

•North America (109)

Resource Types

•Book/Report (4)

•Journal Article (115)

•Legislation/Regulation (1)

•Meeting/Conference (2)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (7)

•Special or Theme Issue (3)

•Tools/Toolkit (2)

•Web Resource (1)

Error Types

•Epidemiology of Errors and Adverse Events (45)

•Active Errors (34)

•Latent Errors (13)

•Near Miss (3)

Approach to Improving Safety

•Quality Improvement Strategies (42)

•Legal and Policy Approaches (7)

•Error Reporting and Analysis (48)

•Communication Improvement (25)

•Human Factors Engineering (16)

•Teamwork (1)

•Specialization of Care (3)

•Logistical Approaches (37)

•Culture of Safety (3)

•Technologic Approaches (31)

•Education and Training (15)

Clinical Areas
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Pathology & Laboratory Medicine

Target Audience

•Health Care Providers (103)

•Health Care Executives and Administrators (85)

•Non-Health Care Professionals (28)

•Patients (5)

Setting of Care

•Hospitals (34)

•Ambulatory Care (16)

1 - 20 of 136

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REVIEW

Patient safety and error reduction in surgical pathology.

Nakhleh RE. Arch Pathol Lab Med. 2008;132:181-185.

ORGANIZATIONAL POLICY/GUIDELINES

Recommendations for quality assurance and improvement in surgical and autopsy pathology.

Association of Directors of Anatomic and Surgical Pathology. Hum Pathol. 2006;37:985-988.

STUDY

Medical errors arising from outsourcing laboratory and radiology services.

Chasin BS, Elliott SP, Klotz SA. Am J Med. 2007;120:819.e9-11.

COMMENTARY

Critical diagnoses (critical values) in anatomic pathology.

Association of Directors of Anatomic and Surgical Pathology. Hum Pathol. 2006;37:982-984.

STUDY

Patient safety in the clinical laboratory: a longitudinal analysis of specimen identification errors.

Wagar EA, Tamashiro L, Yasin B, Hilborne L, Bruckner DA. Arch Pathol Lab Med. 2006;130:1662-1668.

COMMENTARY classic

Errors in laboratory medicine: practical lessons to improve patient safety.

Howanitz PJ. Arch Pathol Lab Med. 2005;129:1252-1261.

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.

STUDY

Identification errors involving clinical laboratories: a College of American Pathologists Q-Probes study of patient and specimen identification errors at 120 institutions.

Valenstein PN, Raab SS, Walsh MK. Arch Pathol Lab Med. 2006;130:1106-1113.

STUDY

Developing and pilot testing practical measures of preanalytic surgical specimen identification defects.

Bixenstine PJ, Zarbo RJ, Holzmueller CG, et al. Am J Med Qual. 2013 Jan 15; [Epub ahead of print].

STUDY

Outside case review of surgical pathology for referred patients: the impact on patient care.

Swapp RE, Aubry MC, Salomão DR, Cheville JC. Arch Pathol Lab Med. 2013;137:233-240.

NEWSLETTER/JOURNAL

Laboratory Errors & Patient Safety.

Seattle, WA: Medical Training Solutions.

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.

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.

NEWSPAPER/MAGAZINE ARTICLE

Follow-up tips for a safe, efficient practice.

Weiss GG. Med Econ. May 19, 2006; 83:47-49.

REVIEW

The safety implications of missed test results for hospitalised patients: a systematic review.

Callen J, Georgiou A, Li J, Westbrook JI. BMJ Qual Saf 2011;20:194-199.

STUDY

Computer-assisted bar-coding system significantly reduces clinical laboratory specimen identification errors in a pediatric oncology hospital.

Hayden RT, Patterson DJ, Jay DW, et al. J Pediatr. 2008;152:219-224.

REVIEW

Identifying cross contaminants and specimen mix-ups in surgical pathology.

Hunt JL. Adv Anat Pathol. 2008;15:211-217.

STUDY

Rate of occult specimen provenance complications in routine clinical practice.

Pfeifer JD, Liu J. Am J Clin Pathol. 2013;139:93-100.

STUDY

Correlation of workload with disagreement and amendment rates in surgical pathology and nongynecologic cytology.

Renshaw AA, Gould EW. Am J Clin Pathol. 2006;125:820-822.

STUDY

Voluntary electronic reporting of laboratory errors: an analysis of 37,532 laboratory event reports from 30 health care organizations.

Snydman LK, Harubin B, Kumar S, Chen J, Lopez RE, Salem DN. Am J Med Qual. 2012;27:147-153.

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