The PSNet Collection: All Content

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.

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Displaying 1 - 6 of 6 Results

Communicating pathology and laboratory errors: anatomic pathologists' and laboratory medical directors' attitudes and experiences.

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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.

Systematic assessment of culture review as a tool to assess errors in the clinical microbiology laboratory.

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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.

A 2-year study of patient safety competency assessment in 29 clinical laboratories.

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Reed RC, Kim S, Farquharson K, et al. Am J Clin Pathol. 2008;129.

A web-based questionnaire was used to assess patient safety knowledge among clinical laboratory staff. The test identified gaps in knowledge regarding effective patient safety interventions.

Right Patient, Wrong Sample

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WebM&M Case December 1, 2006

… in the work environment that encourage shortcutting. … Michael Astion, 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 … Michael L Astion …

Clinical impact associated with corrected results in clinical microbiology testing.

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Yuan S, Astion ML, Schapiro J, et al. J Clin Microbiol. 2005;43:2188-93.

The authors describe a strategy for using corrected lab reports to evaluate laboratory-related adverse events. They conclude that this strategy is effective for identifying preventable adverse events.

The Result Stopped Here

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WebM&M Case June 1, 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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