AHRQ Patient Safety Network

The Collection > Laboratory Result Tracking Improvement

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Safety Target

•Diagnostic Errors (19)

•Identification Errors (17)

•Discontinuities, Gaps, and Hand-Off Problems (61)

•Medication Safety (21)

•Medical Complications (4)

•Surgical Complications (5)

•Transfusion Complications (4)

•Psychological and Social Complications (2)

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•Asia (1)

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•Book/Report (1)

•Journal Article (73)

•Meeting/Conference (1)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (10)

•Special or Theme Issue (1)

•Tools/Toolkit (1)

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Error Types

•Epidemiology of Errors and Adverse Events (17)

•Active Errors (21)

•Latent Errors (13)

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Approach to Improving Safety
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Laboratory Result Tracking Improvement

Clinical Areas

•Medicine (74)

•Nursing (1)

•Pharmacy (5)

Target Audience

•Health Care Providers (65)

•Health Care Executives and Administrators (59)

•Non-Health Care Professionals (33)

•Patients (5)

Setting of Care

•Hospitals (37)

•Residential Facilities (1)

•Ambulatory Care (26)

•Outpatient Surgery (1)

1 - 20 of 89

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NEWSPAPER/MAGAZINE ARTICLE

Lost surgical specimens, lost opportunities.

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

COMMENTARY

2009 National Patient Safety Goals.

Saufl NM. J Perianesth Nurs. 2009;24:114-118.

STUDY

Improving the discharge process by embedding a discharge facilitator in a resident team.

Finn KM, Heffner R, Chang Y, et al. J Hosp Med. 2011;6:494-500.

BOOK/REPORT

Meeting the Joint Commission's 2013 National Patient Safety Goals.

Oakbrook Terrace, IL: The Joint Commission; September 2012. ISBN: 9781599407555.

NEWSPAPER/MAGAZINE ARTICLE

Diagnostic error in acute care.

PA-PSRS Patient Saf Advis. 2010;7:76-86.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2007;42:181–182.

COMMENTARY

The Result Stopped Here.

Astion M. AHRQ WebM&M [serial online]. June 2004.

COMMENTARY

Staggered Sensitivity Results

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

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.

COMMENTARY

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

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

STUDY

The effectiveness of inking needle core prostate biopsies for preventing patient specimen identification errors: a technique to address Joint Commission patient safety goals in specialty laboratories.

Raff LJ, Engel G, Beck KR, O'Brien AS, Bauer ME. Arch Pathol Lab Med. 2009;133:295-297.

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.

COMMENTARY

Lost in the Black Hole.

Wachter RM. AHRQ WebM&M [serial online]. October 2003.

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

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.

COMMENTARY

Ten years after the IOM report: engaging residents in quality and patient safety by creating a house staff quality council.

Fleischut PM, Evans AS, Nugent WC, et al. Am J Med Qual. 2011;26:89-94.

STUDY

Use of electronic health records in US hospitals.

Jha AK, Desroches CM, Campbell EG, et al. N Engl J Med. 2009;360:1628-1638.

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

Hospitals move to cut dangerous lab errors.

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

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.

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