The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.
Dintzis SM, Stetsenko GY, Sitlani CM, et al. Am J Clin Pathol. 2011;135:760-5.
This study surveyed pathologists and hospital laboratory medical directors and found that nearly all reported being involved with an error. While they believed errors should be disclosed, respondents noted inadequate reporting systems and discomfort with their ability to communicate such events to patients.
Goodyear N, Ulness BK, Prentice JL, et al. Arch Pathol Lab Med. 2008;132:1792-5.
This study discovered that errors from positive culture reports most commonly involved susceptibility information and reporting. The authors suggest that careful review of such reports could prevent clinical laboratory errors.
… in the work environment that encourage shortcutting. … MichaelAstion, MD, PhD … Associate Professor and Director of … Arch Pathol Lab Med. 2002;126:809–815. [go to PubMed] 10. Yuan S, Astion ML, Schapiro J, Limaye AP. Clinical impact … regarding patient safety initiatives. … Michael … Astion … L … MichaelLAstion …
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.