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Lost in the Black Hole.
Wachter RM. AHRQ WebM&M [serial online]. October 2003.
A missing lab result leads to a 6-month delay in informing a patient about a new diagnosis of HIV.
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Check the Bags.
Caldwell M, Dracup KA. AHRQ WebM&M [serial online]. September 2003.
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Urine a Tough Position.
Gandhi TK. AHRQ WebM&M [serial online]. October 2003.
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Resource Type
Commentary
Setting of Care
Hospitals
Target Audience
Health Care Providers
Non-Health Care Professionals
Clinical Area
Emergency Medicine
Hospital Medicine
Safety Target
Psychological and Social Complications
Missed or Critical Lab Results
Error Types
Noncognitive Errors ("Slips & Lapses")
Latent Errors
Approach to Improving Safety
Reminders
Read Back Protocols
Structured Hand-offs
Hospitalists
Laboratory Result Tracking Improvement
Technologic Approaches
Origin/Sponsor
Agency for Healthcare Research and Quality (AHRQ)