"Chance favors only the prepared mind": preparing minds to systematically reduce hazards in the testing process in primary care.

Ranjit Singh; John Hickner; Jim Mold; Gurdev Singh

Study

"Chance favors only the prepared mind": preparing minds to systematically reduce hazards in the testing process in primary care.

March 5, 2014

Singh R, Hickner J, Mold J, et al. J Patient Saf. 2014;10(1):20-8.

View more articles from the same authors.

Unreliable test result management systems and failure to follow-up on abnormal test results are common issues in ambulatory care. Using a modified failure mode and effect analysis methodology, this study sought to prospectively identify safety hazards in the laboratory testing process in primary care clinics.

PubMed citation

Available at

Related Resources From the Same Author(s)

Computer visualisation of patient safety in primary care: a systems approach adapted from management science and engineering.

July 20, 2005

Prioritizing threats to patient safety in rural primary care.

May 23, 2007

A patient safety objective structured clinical examination.

June 3, 2009

A comprehensive collaborative patient safety residency curriculum to address the ACGME core competencies.

December 14, 2005

How a series of errors led to recurrent hypoglycemia.

July 12, 2006

Perceptual gaps between clinicians and technologists on health information technology-related errors in hospitals: observational study.

March 3, 2021

Barriers and motivators for making error reports from family medicine offices: a report from the American Academy of Family Physicians National Research Network (AAFP NRN).

March 21, 2007

Differing perceptions of safety culture across job roles in the ambulatory setting: analysis of the AHRQ Medical Office Survey on Patient Safety Culture.

November 11, 2015

Learning from different lenses: reports of medical errors in primary care by clinicians, staff, and patients: a project of the American Academy of Family Physicians National Research Network.

November 1, 2006

Patient, physician, medical assistant, and office visit factors associated with medication list agreement.

March 9, 2016

Better medical office safety culture is not associated with better scores on quality measures.

January 11, 2012

Opportunities to enhance laboratory professionals' role on the diagnostic team.

November 16, 2016

Medication errors reported by US family physicians and their office staff.

August 20, 2008

Resident and nurse perspectives on the use of secure text messaging systems.

October 19, 2022

Potentially Preventable Readmissions: Conceptual Framework To Rethink the Role of Primary Care. Executive Summary.

April 1, 2020

Elimination of emergency department medication errors due to estimated weights.

May 24, 2017

Using an electronic prescribing system to ensure accurate medication lists in a large multidisciplinary medical group.

April 29, 2009

Diagnostic errors in paediatric cardiac intensive care.

February 21, 2018

Using Six Sigma to reduce medication errors in a home-delivery pharmacy service.

June 1, 2005

Adherence to recommended electronic health record safety practices across eight health care organizations.

May 16, 2018

Family Input for Quality and Safety (FIQS): using mobile technology for in-hospital reporting from families and patients.

March 2, 2022

Incivility in healthcare: the impact of poor communication.

August 2, 2023

How can we keep patients with dementia safe in our acute hospitals? A review of challenges and solutions.

July 10, 2013

Impact of computerized prescriber order entry (CPOE) on clinical pharmacy practice: a hypothesis-generating study.

October 24, 2007

Prioritizing patient safety efforts in office practice settings

December 18, 2019

Efficacy and unintended consequences of hard-stop alerts in electronic health record systems: a systematic review.

October 17, 2018

Use of design thinking and human factors approach to improve situation awareness in the pediatric intensive care unit.

November 1, 2023

Antiretroviral medication errors among hospitalized patients with HIV infection.

September 13, 2006

Field test results of a new ambulatory care Medication Error and Adverse Drug Event Reporting System—MEADERS.

December 1, 2010

The use of a CPOE log for the analysis of physicians' behavior when responding to drug-duplication reminders.

September 17, 2008

Mortality risks associated with emergency admissions during weekends and public holidays: an analysis of electronic health records.

June 21, 2017

Using the NAM diagnostic process framework to teach clinical reasoning in computerized case presentations to 251 medical students.

September 9, 2020

SBAR: electronic handoff tool for noncomplicated procedural patients.

January 4, 2012

Testing process errors and their harms and consequences reported from family medicine practices: a study of the American Academy of Family Physicians National Research Network.

June 11, 2008

Types of diagnostic errors reported by paediatric emergency providers in a global paediatric emergency care research network.

May 10, 2023

Mitigation of patient harm from testing errors in family medicine offices: a report from the American Academy of Family Physicians National Research Network.

June 11, 2008

We Want to Know-a mixed methods evaluation of a comprehensive program designed to detect and address patient-reported breakdowns in care.

May 20, 2020

Workplace engagement and workers' compensation claims as predictors for patient safety culture.

October 17, 2012

Artificial intelligence in clinical diagnosis: opportunities, challenges, and hype.

July 19, 2023

A roadmap to advance patient safety in ambulatory care.

January 20, 2021

The path to diagnostic excellence includes feedback to calibrate how clinicians think.

February 20, 2019

Payment innovations to improve diagnostic accuracy and reduce diagnostic error.

November 7, 2018

Conspicuous by its absence: diagnostic expert testing under uncertainty.

March 25, 2020

Inpatient notes: reducing diagnostic error—a new horizon of opportunities for hospital medicine.

October 26, 2016

The challenges in defining and measuring diagnostic error.

June 24, 2015

Intensive care unit nurses' information needs and recommendations for integrated displays to improve nurses' situation awareness.

April 11, 2012

Two decades since To Err Is Human: an assessment of progress and emerging priorities in patient safety.

November 7, 2018

Policies to promote shared responsibility for safer electronic health records.

September 29, 2021

A sociotechnical framework for safety-related electronic health record research reporting: the SAFER reporting framework.

June 24, 2020

Reducing the risk of diagnostic error in the COVID-19 era.

May 27, 2020

Assigning responsibility to close the loop on radiology test results.

July 12, 2017

General internists in pursuit of diagnostic excellence in primary care: a #ProudtobeGIM thread that unites us all.

April 18, 2018

Toward more proactive approaches to safety in the electronic health record era.

September 13, 2017

The Food and Drug Administration's initiative for safe design and effective use of home medical equipment.

June 18, 2014

Electronic health records and National Patient-Safety Goals.

November 21, 2012

Measuring and improving patient safety through health information technology: the Health IT Safety Framework.

October 14, 2015

Eight recommendations for policies for communicating abnormal test results.

May 5, 2010

Eight rights of safe electronic health record use.

September 23, 2009

Reducing diagnostic error through medical home-based primary care reform.

August 11, 2010

Improving diagnosis in health care—the next imperative for patient safety.

November 18, 2015

Defining health information technology–related errors: new developments since To Err Is Human.

August 3, 2011

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

January 30, 2005

Advancing the science of measurement of diagnostic errors in healthcare: the Safer Dx framework.

January 28, 2015

We want to know: patient comfort speaking up about breakdowns in care and patient experience.

October 17, 2018

Factors contributing to all-cause 30-day readmissions: a structured case series across 18 hospitals.

October 10, 2012

Measure Dx: implementing pathways to discover and learn from diagnostic errors.

September 28, 2022

A scoping review of communication tools applicable to patients and their primary care providers after discharge from hospital.

July 14, 2021

Diagnostic errors in the neonatal intensive care unit: state of the science and new directions.

October 23, 2019

Using fault trees to advance understanding of diagnostic errors.

November 1, 2017

Understanding missed opportunities for more timely diagnosis of cancer in symptomatic patients after presentation.

May 20, 2015

Advancing the research agenda for diagnostic error reduction.

August 28, 2013

Using prospective clinical surveillance to identify adverse events in hospital.

March 30, 2011

Incidence and predictors of opioid prescription at discharge after traumatic injury.

July 12, 2017

Experience with a trigger tool for identifying adverse drug events among older adults in ambulatory primary care.

June 17, 2009

Advancing diagnostic equity through clinician engagement, community partnerships, and connected care.

February 22, 2023

Five strategies for clinicians to advance diagnostic excellence.

March 2, 2022

Guidelines for US hospitals and clinicians on assessment of electronic health record safety using SAFER Guides.

February 16, 2022

Operational measurement of diagnostic safety: state of the science.

October 7, 2020

Developing health care organizations that pursue learning and exploration of diagnostic excellence: an action plan.

December 4, 2019

A decade of health information technology usability challenges and the path forward.

February 13, 2019

Applying requisite imagination to safeguard electronic health record transitions.

May 18, 2022

Tracking progress in improving diagnosis: a framework for defining undesirable diagnostic events.

February 14, 2018

Electronic health record alert–related workload as a predictor of burnout in primary care providers.

August 30, 2017

Improving the safety of health information technology requires shared responsibility: it is time we all step up.

August 2, 2017

Contingency planning for electronic health record–based care continuity: a survey of recommended practices.

October 15, 2014

The frequency of diagnostic errors in outpatient care: estimations from three large observational studies involving US adult populations.

April 30, 2014

Crowdsourcing diagnosis for patients with undiagnosed illnesses: an evaluation of CrowdMed.

February 3, 2016

Creating an oversight infrastructure for electronic health record–related patient safety hazards.

November 30, 2011

Communicating findings of delayed diagnostic evaluation to primary care providers.

July 27, 2016

Patient safety goals for the proposed Federal Health Information Technology Safety Center.

November 19, 2014

Mistake-proofing healthcare: why stopping processes may be a good start.

March 3, 2010

Fighting a common enemy: a catalyst to close intractable safety gaps.

August 5, 2020

Bridging the feedback gap: a sociotechnical approach to informing clinicians of patients' subsequent clinical course and outcomes.

June 30, 2021

Diagnostic decision-making in the emergency department.

January 9, 2019

Teaching novice clinicians how to reduce diagnostic waste and errors by applying the Toyota Production System.

April 10, 2019

Diagnostic error in the critically ill: defining the problem and exploring next steps to advance intensive care unit safety.

October 24, 2018

Recommendations for using the Revised Safer Dx instrument to help measure and improve diagnostic safety.

August 21, 2019

Adherence to national guidelines for timeliness of test results communication to patients in the Veterans Affairs health care system.

May 4, 2022

Stigmatizing language expressed towards individuals with current or previous OUD who have pain and cancer: a qualitative study.

June 14, 2023

Measures to improve diagnostic safety in clinical practice.

November 2, 2016

Related Resources

Implementing a safer and more reliable system to monitor test results at a teaching university-affiliated facility in a family medicine group: a quality improvement process report.

November 1, 2023

Identifying failure modes in telemedicine: an instructional needs assessment.

August 9, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Interdisciplinary clinicians' attitudes, challenges, and success strategies in providing care to transgender people: a qualitative descriptive study.

October 19, 2022

Clinician distress and inappropriate antibiotic prescribing for acute respiratory tract infections: a retrospective cohort study.

May 11, 2022

Laboratory test ordering and results management systems: a qualitative study of safety risks identified by administrators in general practice.

March 12, 2014

From physician intent to the pharmacy label: prevalence and description of discrepancies from a cross-sectional evaluation of electronic prescriptions.

February 26, 2014

Primary care physician communication at hospital discharge reduces medication discrepancies.

December 18, 2013

Toward increased patient safety? Electronic communication of medication information between nurses in home health care and general practitioners.

November 6, 2013

Patient Safety Toolkits.

October 30, 2013

Using a patient internet portal to prevent adverse drug events: a randomized, controlled trial.

September 11, 2013

Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients.

August 21, 2013

Impact of individual and team features of patient safety climate: a survey in family practices.

August 14, 2013

Adherence to drug–drug interaction alerts in high-risk patients: a trial of context-enhanced alerting.

August 7, 2013

Resilient actions in the diagnostic process and system performance.

July 17, 2013

Safety climate and its association with office type and team involvement in primary care.

May 29, 2013

Developing and pilot testing practical measures of preanalytic surgical specimen identification defects.

March 27, 2013

Types and origins of diagnostic errors in primary care settings.

March 6, 2013

Reasons for not reporting patient safety incidents in general practice: a qualitative study.

January 30, 2013

The relationship of self-report of quality to practice size and health information technology.

October 10, 2012

Are health professionals' perceptions of patient safety related to figures on safety incidents?

September 19, 2012

Medication safety in primary care practice: results from a PPRNet quality improvement intervention.

July 11, 2012

Challenges of making a diagnosis in the outpatient setting: a multi-site survey of primary care physicians.

June 6, 2012

Medical errors reported by French general practitioners in training: results of a survey and individual interviews.

April 4, 2012

Medication reconciliation campaign in a clinic for homeless patients.

April 4, 2012

Identifying discrepancies in electronic medical records through pharmacist medication reconciliation.

March 21, 2012

Emotional impact of patient safety incidents on family physicians and their office staff.

March 21, 2012

Measuring perceptions of safety climate in primary care: a cross-sectional study.

February 29, 2012

Better medical office safety culture is not associated with better scores on quality measures.

January 11, 2012

Receptionist input to quality and safety in repeat prescribing in UK general practice: ethnographic case study.

November 16, 2011

See More About The Topic

Ambulatory Clinic or Office

Health Care Providers

Quality and Safety Professionals

Family Medicine

Primary Care

"Chance favors only the prepared mind": preparing minds to systematically reduce hazards in the testing process in primary care.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

"Chance favors only the prepared mind": preparing minds to systematically reduce hazards in the testing process in primary care.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site