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 (68)

Resource Types

•Book/Report (2)

•Journal Article (65)

•Legislation/Regulation (1)

•Meeting/Conference (1)

•Newspaper/Magazine Article (6)

•Special or Theme Issue (2)

•Tools/Toolkit (1)

•Web Resource (1)

Error Types

•Epidemiology of Errors and Adverse Events (25)

•Active Errors (22)

•Latent Errors (11)

•Near Miss (1)

Approach to Improving Safety

•Quality Improvement Strategies (20)

•Legal and Policy Approaches (5)

•Error Reporting and Analysis (14)

•Communication Improvement (28)

•Human Factors Engineering (7)

•Teamwork (2)

•Specialization of Care (2)

•Logistical Approaches (45)

•Culture of Safety (4)

•Technologic Approaches (31)

•Education and Training (7)

Clinical Areas

•Medicine (66)

•Nursing (2)

•Pharmacy (2)

Target Audience

•Health Care Providers (56)

•Health Care Executives and Administrators (47)

•Non-Health Care Professionals (27)

•Patients (6)

Setting of Care

•Hospitals (33)

•Ambulatory Care (22)

1 - 20 of 79

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REVIEW

Patient safety and error reduction in surgical pathology.

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

STUDY

Medical errors arising from outsourcing laboratory and radiology services.

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

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.

STUDY

Studying critical values: adverse event identification following a critical laboratory values study at the Ohio State University Medical Center.

Jenkins JJ, Mac Crawford J, Bissell MG. Am J Clin Pathol. 2007;128:604-609.

STUDY

Classifying laboratory incident reports to identify problems that jeopardize patient safety.

Astion ML, Shojania KG, Hamill TR, Kim S, Ng VL. Am J Clin Pathol. 2003;120:18-26.

BOOK/REPORT

Why Current Breast Pathology Practices Must Be Evaluated.

Dallas, TX: Susan G. Komen Breast Cancer Foundation; June 2006.

STUDY

Rate of occult specimen provenance complications in routine clinical practice.

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

STUDY

The frequency of missed test results and associated treatment delays in a highly computerized health system.

Wahls TL, Cram PM. BMC Fam Pract. 2007;8:32.

STUDY

Systematic assessment of culture review as a tool to assess errors in the clinical microbiology laboratory.

Goodyear N, Ulness BK, Prentice JL, Cookson BT, Limaye AP. Arch Pathol Lab Med. 2008;132:1792-1795.

STUDY

Clinical impact associated with corrected results in clinical microbiology testing.

Yuan S, Astion ML, Schapiro J, Limaye AP. J Clin Microbiol. 2005;43:2188-2193.

STUDY

Standardized patient identification and specimen labeling: a retrospective analysis on improving patient safety.

Kim JK, Dotson B, Thomas S, Nelson KC. J Am Acad Dermatol. 2013;68:53-56.

STUDY

Patient safety concerns arising from test results that return after hospital discharge.

Roy CL, Poon EG, Karson AS, et al. Ann Intern Med. 2005;143:121-128.

STUDY

Communication outcomes of critical imaging results in a computerized notification system.

Singh H, Arora HS, Vij MS, Rao R, Khan MM, Petersen LA. J Am Med Inform Assoc. 2007;14:459-466.

COMMENTARY

Should patients get direct access to their laboratory test results?: An answer with many questions.

Davis Giardina T, Singh H. JAMA. 2011;306:2502-2503.

STUDY

Follow-up of outpatient test results: a survey of house-staff practices and perceptions.

Lin JJ, Dunn A, Moore C. Am J Med Qual. 2006;21:178-184.

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.

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.

TOOLKIT

Communicating Critical Test Results.

Burlington, MA: Massachusetts Coalition for the Prevention of Medical Errors; 2003.

STUDY

Improving patient safety via automated laboratory-based adverse event grading.

Niland JC, Stiller T, Neat J, Londrc A, Johnson D, Pannoni S. J Am Med Inform Assoc. 2012;19:111-115.

NEWSPAPER/MAGAZINE ARTICLE

Lost surgical specimens, lost opportunities.

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

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