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The Result Stopped Here.
Astion M. AHRQ WebM&M [serial online]. June 2004.
Just before leaving for the weekend, a physician orders a test for a communicable infection. Although the result arrives and isolation signs are placed on the patient's door, none of the covering physicians are notified, and the float nurses mistakenly assume the patient is already receiving treatment.
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Resource Type
Commentary
Setting of Care
Hospitals
Target Audience
Health Care Providers
Non-Health Care Professionals
Clinical Area
Pathology & Laboratory Medicine
Medical/Surgical/Psychiatric Nursing
Infectious Diseases
Safety Target
Ordering/Prescribing Errors
Administration Errors
Missed or Critical Lab Results
Error Types
Noncognitive Errors ("Slips & Lapses")
Cognitive Errors ("Mistakes")
Latent Errors
Approach to Improving Safety
Communication between Providers
Structured Hand-offs
Laboratory Result Tracking Improvement
Origin/Sponsor
Agency for Healthcare Research and Quality (AHRQ)