Study Classifying laboratory incident reports to identify problems that jeopardize patient safety. Citation Text: Astion ML; Shojania KG; Hamill TR; Kim S; Ng VL. Copy Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL September 7, 2005 Astion ML; Shojania KG; Hamill TR; Kim S; Ng VL. View more articles from the same authors. The investigators describe a system for classifying errors in clinical laboratories. PubMed citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Cite Citation Citation Text: Astion ML; Shojania KG; Hamill TR; Kim S; Ng VL. Copy Citation Related Resources From the Same Author(s) Medication reconciliation in the hospital: what, why, where, when, who and how? May 2, 2012 Making Health Care Safer: A Critical Analysis of Patient Safety Practices. March 27, 2005 Handoffs and fumbles. March 27, 2005 Entire UPMC transplant team missed hepatitis alert. July 20, 2011 Ability of practitioners to identify solid oral dosage tablets. May 24, 2006 Striving for high reliability in healthcare: a qualitative study of the implementation of a hospital safety programme. June 22, 2022 Incident reporting systems: what will it take to make them less frustrating and achieve anything useful? December 1, 2021 Looking back on the history of patient safety: an opportunity to reflect and ponder future challenges. November 3, 2021 Temporal trends in patient safety in the Netherlands: reductions in preventable adverse events or the end of adverse events as a useful metric? August 5, 2015 Putting out fires: a qualitative study exploring the use of patient complaints to drive improvement at three academic hospitals. July 10, 2019 Patient safety in emergency medical services: a systematic review of the literature. December 21, 2011 Effects of rapid response systems on clinical outcomes: systematic review and meta-analysis. January 2, 2008 New evidence on stemming low-value prescribing. May 1, 2019 Report on the Safe Use of Pick Lists in Ambulatory Care Settings. December 7, 2016 Cause for concern: drug shortages disrupt operations, tax hospitalists' treatment patterns. July 20, 2011 Drug-related hospital admissions. March 27, 2005 Cognitive Informatics: Reengineering Clinical Workflow for Safer and More Efficient Care. August 21, 2019 Taking the Lead in Patient Safety: How Healthcare Leaders Influence Behavior and Create Culture. April 22, 2009 Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes. Updated edition. March 27, 2005 Biomedical Complexity and Error. July 13, 2011 Nursing home administrators' opinions of the resident safety culture in nursing homes. February 7, 2007 Assessing resident safety culture in nursing homes: using the nursing home survey on resident safety. December 2, 2009 Responding to health information technology reported safety events: insights from patient safety event reports. June 12, 2019 Structured override reasons for drug–drug interaction alerts in electronic health records. May 15, 2019 Demanding Medical Excellence. Doctors and Accountability in the Information Age. March 6, 2005 Show me the money, I'll show you my complications: impacts of incentivized incident self-reporting among surgeons. March 2, 2022 Interprofessional model on speaking up behaviour in healthcare professionals: a qualitative study. May 25, 2022 Patient safety culture: the impact on workplace violence and health worker burnout. February 8, 2023 How does workplace violence-reporting culture affect workplace violence, nurse burnout, and patient safety? December 7, 2022 Detection of missed fractures of hand and forearm in whole-body CT in a blinded reassessment. September 29, 2021 Situativity: A Family of Social Cognitive Theories for Clinical Reasoning and Error. August 26, 2020 Patient Safety in Ambulatory Settings. November 2, 2016 Recent Evidence That Health IT Improves Patient Safety: Issue Brief. May 13, 2015 Man falls off surgical table; St. Joseph's Hospital sued. August 4, 2010 Reducing patient risk from prescription instruction errors—a six sigma approach. June 18, 2008 Goals and Priorities for Health Care Organizations to Improve Safety Using Health IT. Revised Report. June 29, 2016 Opioid-Related Inpatient Stays and Emergency Department Visits Among Patients Aged 65 Years and Older, 2010 and 2015. October 3, 2018 Improving patient safety with team coordination: challenges and strategies of implementation. August 9, 2006 The safety of intravenous drug delivery systems: update on current issues since the 1999 Consensus Development Conference. March 4, 2009 Adverse Drug Events in U.S. Hospitals, 2010 Versus 2014. March 14, 2018 Diagnosis: Interpreting the Shadows. July 26, 2017 An analysis of the structure and content of dashboards used to monitor patient safety in the inpatient setting. December 8, 2021 Improving Telediagnosis--a Call to Action: Final Project Findings. October 13, 2021 Diagnostic experiences of children with attention-deficit/hyperactivity disorder. September 30, 2015 Trends in Potentially Preventable Inpatient Hospital Admissions and Emergency Department Visits. May 11, 2016 Opioid-Related Inpatient Stays and Emergency Department Visits by State, 2009–2014. January 11, 2017 Patient safety measurement tools used in nursing homes: a systematic literature review. December 7, 2022 Implicit bias and caring for diverse populations: pediatric trainee attitudes and gaps in training. September 22, 2021 Agreement between patient-reported symptoms and their documentation in the medical record. August 27, 2008 Best-practice protocols: preventing adverse drug events. September 28, 2005 Diagnostic Error: Is Overconfidence the Problem. May 14, 2008 When less is more: the role of overdiagnosis and overtreatment in patient safety. September 29, 2021 Dealing with a medical mistake: should physicians apologize to patients? November 20, 2013 The July effect: an analysis of never events in the nationwide inpatient sample. April 15, 2015 Voluntary medical incident reporting tool to improve physician reporting of medical errors in an emergency department. February 17, 2016 Safety culture of nursing homes: opinions of top managers. April 6, 2011 Diagnostic Error in Medicine. October 7, 2009 Nursing interventions to reduce medication errors in paediatrics and neonates: systematic review and meta-analysis. December 8, 2021 How to mitigate the effects of cognitive biases during patient safety incident investigations. September 28, 2022 Workplace violence against anesthesiologists: we are not immune to this patient safety threat. September 18, 2019 Effect of a multispecialty faculty handoff initiative on safety culture and handoff quality. April 20, 2022 A bottom-up approach addressing patient care and differential diagnosis amidst the Covid-19 response. October 14, 2020 The relationship of organizational culture, stress, satisfaction, and burnout with physician-reported error and suboptimal patient care: results from the MEMO study. August 15, 2007 The 2004 John M. Eisenberg Patient Safety and Quality Awards. March 6, 2005 Can SBAR be implemented with high fidelity and does it improve communication between healthcare workers? A systematic review. January 12, 2022 Implementing a robust process improvement program in the neonatal intensive care unit to reduce harm. April 13, 2022 Ambulatory medication safety in primary care: a systematic review. July 6, 2022 Potentially inappropriate medication administration is associated with adverse postoperative outcomes in older surgical patients: a retrospective cohort study. September 14, 2022 How should clinicians minimize bias when responding to suspicions about child abuse? February 22, 2023 Defining and enhancing collaboration between community pharmacists and primary care providers to improve medication safety. February 22, 2023 Renal medication-related clinical decision support (CDS) alerts and overrides in the inpatient setting following implementation of a commercial electronic health record: implications for designing more effective alerts. February 17, 2021 Improving Diagnosis in Radiology—Progress and Proposals. September 13, 2017 Medication errors in overweight and obese pediatric patients: a systematic review. February 9, 2022 Adverse events in infants less than 6 months of age after ambulatory surgery and diagnostic imaging requiring anesthesia. August 10, 2022 Prescribing decision making by medical residents on night shifts: a qualitative study. November 9, 2022 Duplicate medication order errors: safety gaps and recommendations for improvement. October 12, 2022 Nearly all thirty most frequently used emergency department drugs experienced shortages from 2006-2019. April 27, 2022 Anatomy of a cyberattack: part 4: quality assurance and error reduction, billing and compliance, transition to uptime. April 27, 2022 Health information technology-related wrong-patient errors: context is critical. January 27, 2021 Bracing for the storm: one health care system's planning for the COVID-19 surge. November 11, 2020 Race, postoperative complications, and death in apparently healthy children. August 12, 2020 Maximum emergency department overcrowding is correlated with occurrence of unexpected cardiac arrest. July 8, 2020 Hospital infections hard to gauge. April 28, 2010 WebM&M Cases Right Patient, Wrong Sample December 1, 2006 WebM&M Cases The Result Stopped Here June 1, 2004 Resident Safety Practices in Nursing Home Settings. November 11, 2015 The State of the Science on Safe Medication Administration. April 15, 2005 Assessment of a simulated case-based measurement of physician diagnostic performance. January 23, 2019 Diagnostic error in pediatrics: a narrative review. March 23, 2022 Association of anesthesiologist staffing ratio with surgical patient morbidity and mortality. August 3, 2022 Adverse event reporting priorities: an integrative review. June 29, 2022 Safety learning among young newly employed workers in three sectors: a challenge to the assumed order of things. November 17, 2021 Directed peer review in surgical pathology. September 1, 2012 The hidden risk of wheelchair use. September 28, 2022 Analysis of hospital-level readmission rates and variation in adverse events among patients with pneumonia in the United States. June 22, 2022 A call to action: next steps to advance diagnosis education in the health professions. June 8, 2022 The effect of a Lean quality improvement implementation program on surgical pathology specimen accessioning and gross preparation error frequency. September 1, 2012 A human factors intervention in a hospital--evaluating the outcome of a TeamSTEPPS program in a surgical ward. April 14, 2021 Closing the loop on test results to reduce communication failures: a rapid review of evidence, practice and patient perspectives. November 25, 2020 Errors in breast imaging: how to reduce errors and promote a safety environment. July 7, 2021 View More 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 The nature, causes, and clinical impact of errors in the clinical laboratory testing process leading to diagnostic error: a voluntary incident report analysis. October 25, 2023 The delivery of safe and effective test result communication, management and follow-up. September 27, 2023 Patient Safety Innovations Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer July 31, 2023 Diagnostic errors in musculoskeletal oncology and possible mitigation strategies. May 24, 2023 Delays in care during the COVID-19 pandemic in the Veterans Health Administration. May 3, 2023 Annual Perspective Improving Diagnostic Safety and Quality April 26, 2023 Patient Safety Innovations Journal Article Study Catching those who fall through the cracks: integrating a follow-up process for emergency department patients with incidental radiologic findings. November 16, 2022 Are pathologists self-aware of their diagnostic accuracy? Metacognition and the diagnostic process in pathology. October 5, 2022 Adherence to national guidelines for timeliness of test results communication to patients in the Veterans Affairs health care system. May 4, 2022 Technology-based closed-loop tracking for improving communication and follow-up of pathology results. February 2, 2022 Application of human factors methods to understand missed follow-up of abnormal test results. November 11, 2020 WebM&M Cases Pre-analytical pitfalls: Missing and mislabeled specimens February 26, 2020 Error Reduction and Prevention in Surgical Pathology, Second Edition. August 28, 2019 Building an ambulatory safety program at an academic health system. May 15, 2019 Deny, Dismiss, Dehumanise: What Happened When I Went to Hospital. May 1, 2019 Reducing diagnostic errors worldwide through diagnostic management teams. April 3, 2019 Measuring the rate of manual transcription error in outpatient point-of-care testing. March 13, 2019 The effect of a clinical decision support for pending laboratory results at emergency department discharge. February 13, 2019 Blood sampling guidelines with focus on patient safety and identification—a review. October 31, 2018 Understanding test results follow-up in the ambulatory setting: analysis of multiple perspectives. October 24, 2018 Double reading in breast cancer screening: cohort evaluation in the CO-OPS trial. August 29, 2018 WebM&M Cases Failed Interpretation of Screening Tool: Delayed Treatment September 1, 2017 Diagnostic stewardship—leveraging the laboratory to improve antimicrobial use. August 16, 2017 WebM&M Cases Delayed Recognition of a Positive Blood Culture July 1, 2017 Electronic detection of delayed test result follow-up in patients with hypothyroidism. February 15, 2017 Reduction in hospital-wide clinical laboratory specimen identification errors following process interventions: a 10-year retrospective observational study. October 26, 2016 Radiologist-initiated double reading of abdominal CT: retrospective analysis of the clinical importance of changes to radiology reports. August 3, 2016 The forgotten tourniquet—an update. March 13, 2016 Improving radiology report quality by rapidly notifying radiologist of report errors. October 14, 2015 View More See More About The Topic Clinical Technologists Risk Managers Quality and Safety Professionals Pathology and Laboratory Medicine Missed or Critical Lab Results View More
Striving for high reliability in healthcare: a qualitative study of the implementation of a hospital safety programme. June 22, 2022
Incident reporting systems: what will it take to make them less frustrating and achieve anything useful? December 1, 2021
Looking back on the history of patient safety: an opportunity to reflect and ponder future challenges. November 3, 2021
Temporal trends in patient safety in the Netherlands: reductions in preventable adverse events or the end of adverse events as a useful metric? August 5, 2015
Putting out fires: a qualitative study exploring the use of patient complaints to drive improvement at three academic hospitals. July 10, 2019
Patient safety in emergency medical services: a systematic review of the literature. December 21, 2011
Effects of rapid response systems on clinical outcomes: systematic review and meta-analysis. January 2, 2008
Cause for concern: drug shortages disrupt operations, tax hospitalists' treatment patterns. July 20, 2011
Cognitive Informatics: Reengineering Clinical Workflow for Safer and More Efficient Care. August 21, 2019
Taking the Lead in Patient Safety: How Healthcare Leaders Influence Behavior and Create Culture. April 22, 2009
Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes. Updated edition. March 27, 2005
Nursing home administrators' opinions of the resident safety culture in nursing homes. February 7, 2007
Assessing resident safety culture in nursing homes: using the nursing home survey on resident safety. December 2, 2009
Responding to health information technology reported safety events: insights from patient safety event reports. June 12, 2019
Structured override reasons for drug–drug interaction alerts in electronic health records. May 15, 2019
Show me the money, I'll show you my complications: impacts of incentivized incident self-reporting among surgeons. March 2, 2022
Interprofessional model on speaking up behaviour in healthcare professionals: a qualitative study. May 25, 2022
How does workplace violence-reporting culture affect workplace violence, nurse burnout, and patient safety? December 7, 2022
Detection of missed fractures of hand and forearm in whole-body CT in a blinded reassessment. September 29, 2021
Goals and Priorities for Health Care Organizations to Improve Safety Using Health IT. Revised Report. June 29, 2016
Opioid-Related Inpatient Stays and Emergency Department Visits Among Patients Aged 65 Years and Older, 2010 and 2015. October 3, 2018
Improving patient safety with team coordination: challenges and strategies of implementation. August 9, 2006
The safety of intravenous drug delivery systems: update on current issues since the 1999 Consensus Development Conference. March 4, 2009
An analysis of the structure and content of dashboards used to monitor patient safety in the inpatient setting. December 8, 2021
Trends in Potentially Preventable Inpatient Hospital Admissions and Emergency Department Visits. May 11, 2016
Patient safety measurement tools used in nursing homes: a systematic literature review. December 7, 2022
Implicit bias and caring for diverse populations: pediatric trainee attitudes and gaps in training. September 22, 2021
Agreement between patient-reported symptoms and their documentation in the medical record. August 27, 2008
Voluntary medical incident reporting tool to improve physician reporting of medical errors in an emergency department. February 17, 2016
Nursing interventions to reduce medication errors in paediatrics and neonates: systematic review and meta-analysis. December 8, 2021
How to mitigate the effects of cognitive biases during patient safety incident investigations. September 28, 2022
Workplace violence against anesthesiologists: we are not immune to this patient safety threat. September 18, 2019
Effect of a multispecialty faculty handoff initiative on safety culture and handoff quality. April 20, 2022
A bottom-up approach addressing patient care and differential diagnosis amidst the Covid-19 response. October 14, 2020
The relationship of organizational culture, stress, satisfaction, and burnout with physician-reported error and suboptimal patient care: results from the MEMO study. August 15, 2007
Can SBAR be implemented with high fidelity and does it improve communication between healthcare workers? A systematic review. January 12, 2022
Implementing a robust process improvement program in the neonatal intensive care unit to reduce harm. April 13, 2022
Potentially inappropriate medication administration is associated with adverse postoperative outcomes in older surgical patients: a retrospective cohort study. September 14, 2022
How should clinicians minimize bias when responding to suspicions about child abuse? February 22, 2023
Defining and enhancing collaboration between community pharmacists and primary care providers to improve medication safety. February 22, 2023
Renal medication-related clinical decision support (CDS) alerts and overrides in the inpatient setting following implementation of a commercial electronic health record: implications for designing more effective alerts. February 17, 2021
Adverse events in infants less than 6 months of age after ambulatory surgery and diagnostic imaging requiring anesthesia. August 10, 2022
Prescribing decision making by medical residents on night shifts: a qualitative study. November 9, 2022
Nearly all thirty most frequently used emergency department drugs experienced shortages from 2006-2019. April 27, 2022
Anatomy of a cyberattack: part 4: quality assurance and error reduction, billing and compliance, transition to uptime. April 27, 2022
Maximum emergency department overcrowding is correlated with occurrence of unexpected cardiac arrest. July 8, 2020
Assessment of a simulated case-based measurement of physician diagnostic performance. January 23, 2019
Association of anesthesiologist staffing ratio with surgical patient morbidity and mortality. August 3, 2022
Safety learning among young newly employed workers in three sectors: a challenge to the assumed order of things. November 17, 2021
Analysis of hospital-level readmission rates and variation in adverse events among patients with pneumonia in the United States. June 22, 2022
The effect of a Lean quality improvement implementation program on surgical pathology specimen accessioning and gross preparation error frequency. September 1, 2012
A human factors intervention in a hospital--evaluating the outcome of a TeamSTEPPS program in a surgical ward. April 14, 2021
Closing the loop on test results to reduce communication failures: a rapid review of evidence, practice and patient perspectives. November 25, 2020
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
The nature, causes, and clinical impact of errors in the clinical laboratory testing process leading to diagnostic error: a voluntary incident report analysis. October 25, 2023
The delivery of safe and effective test result communication, management and follow-up. September 27, 2023
Patient Safety Innovations Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer July 31, 2023
Patient Safety Innovations Journal Article Study Catching those who fall through the cracks: integrating a follow-up process for emergency department patients with incidental radiologic findings. November 16, 2022
Are pathologists self-aware of their diagnostic accuracy? Metacognition and the diagnostic process in pathology. October 5, 2022
Adherence to national guidelines for timeliness of test results communication to patients in the Veterans Affairs health care system. May 4, 2022
Technology-based closed-loop tracking for improving communication and follow-up of pathology results. February 2, 2022
Application of human factors methods to understand missed follow-up of abnormal test results. November 11, 2020
The effect of a clinical decision support for pending laboratory results at emergency department discharge. February 13, 2019
Understanding test results follow-up in the ambulatory setting: analysis of multiple perspectives. October 24, 2018
Electronic detection of delayed test result follow-up in patients with hypothyroidism. February 15, 2017
Reduction in hospital-wide clinical laboratory specimen identification errors following process interventions: a 10-year retrospective observational study. October 26, 2016
Radiologist-initiated double reading of abdominal CT: retrospective analysis of the clinical importance of changes to radiology reports. August 3, 2016
Improving radiology report quality by rapidly notifying radiologist of report errors. October 14, 2015