AHRQ Patient Safety Network

The Collection > Missed or Critical Lab Results

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Missed or Critical Lab Results

Origin/Sponsor

•Asia (2)

•Australia and New Zealand (1)

•Europe (4)

•North America (72)

Resource Types

•Book/Report (2)

•Journal Article (67)

•Legislation/Regulation (1)

•Meeting/Conference (1)

•Newspaper/Magazine Article (7)

•Special or Theme Issue (2)

•Tools/Toolkit (1)

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Error Types

•Epidemiology of Errors and Adverse Events (25)

•Active Errors (23)

•Latent Errors (12)

•Near Miss (1)

Approach to Improving Safety

•Quality Improvement Strategies (21)

•Legal and Policy Approaches (5)

•Error Reporting and Analysis (15)

•Communication Improvement (30)

•Human Factors Engineering (6)

•Teamwork (2)

•Specialization of Care (3)

•Logistical Approaches (48)

•Culture of Safety (3)

•Technologic Approaches (34)

•Education and Training (6)

Clinical Areas

•Medicine (68)

•Nursing (2)

•Pharmacy (2)

Target Audience

•Health Care Providers (59)

•Health Care Executives and Administrators (46)

•Non-Health Care Professionals (29)

•Patients (6)

Setting of Care

•Hospitals (34)

•Ambulatory Care (22)

1 - 20 of 82

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COMMENTARY

Preparing your hospital for compliance with The Joint Commission's National Patient Safety Goals.

Murdaugh L, Jordin R. Hosp Pharm. 2008;43:728-733.

STUDY

Lessons learned from implementation of a computerized application for pending tests at hospital discharge.

Dalal AK, Poon EG, Karson AS, Gandhi TK, Roy CL. J Hosp Med. 2011;6:16-21.

NEWSPAPER/MAGAZINE ARTICLE

Don't let a hospital make you sick.

Mishori R. Parade Magazine. February 8, 2009.

NEWSPAPER/MAGAZINE ARTICLE

Lost surgical specimens, lost opportunities.

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

STUDY

Trends in primary care clinician perceptions of a new electronic health record.

El-Kareh R, Gandhi TK, Poon EG, et al. J Gen Intern Med. 2009;24:464-468.

STUDY

Early readmissions to the department of medicine as a screening tool for monitoring quality of care problems.

Balla U, Malnick S, Schattner A. Medicine (Baltimore). 2008;87:294-300.

STUDY

Last orders: follow-up of tests ordered on the day of hospital discharge.

Ong MS, Magrabi F, Jones G, Coiera E. Arch Intern Med. 2012;172:1347-1349.

STUDY

Management of test results in family medicine offices.

Elder NC, McEwen TR, Flach JM, Gallimore JJ. Ann Fam Med. 2009;7:343-351.

STUDY

The management of test results in primary care: does an electronic medical record make a difference?

Elder NC, McEwen TR, Flach J, Gallimore J, Pallerla H. Fam Med. 2010;42:327-333.

STUDY

Concept and development of a discharge alert filter for abnormal laboratory values coupled with computerized provider order entry: a tool for quality improvement and hospital risk management.

Mathew G, Kho A, Dexter P, et al. J Patient Saf. 2012;8:69-75.

COMMENTARY

Staggered Sensitivity Results

Guglielmo BJ. AHRQ WebM&M [serial online]. March 2007.

STUDY

Failure to recognize newly identified aortic dilations in a health care system with an advanced electronic medical record.

Gordon JRS, Wahls T, Carlos RC, Pipinos II, Rosenthal GE, Cram P. Ann Intern Med. 2009;151:21-27.

COMMENTARY

A 60-year-old man with delayed care for a renal mass.

Schiff GD. JAMA. 2011;305:1890-1898.

COMMENTARY

Incomplete care—on the trail of flaws in the system.

Gandhi TK, Zuccotti G, Lee TH. N Engl J Med. 2011;365:486-488.

STUDY

Direct reporting of laboratory test results to patients by mail to enhance patient safety.

Sung S, Forman-Hoffman V, Wilson MC, Cram P. J Gen Intern Med. 2006;21:1075-78.

NEWSPAPER/MAGAZINE ARTICLE

The short life and lonely death of Sabrina Seelig.

Hartocollis A. New York Times. July 28, 2012.

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.

NEWSPAPER/MAGAZINE ARTICLE

An infection, unnoticed, turns unstoppable.

Dwyer J. New York Times. July 11, 2012.

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.

NEWSPAPER/MAGAZINE ARTICLE

Safe patient outcomes occur with timely, standardized communication of critical values.

PA-PSRS Patient Saf Advis. September 2009;6:93-97.

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