Finding blunders in thyroid testing: experience in newborns.

Laurel J. Zilka; John A. Lott; Lula C. Baker; Sharon M. Linard

Study

Finding blunders in thyroid testing: experience in newborns.

July 30, 2008

Zilka LJ, Lott JA, Baker LC, et al. J Clin Lab Anal. 2008;22(4):254-6.

View more articles from the same authors.

Inconsistent and possibly erroneous results of thyroid tests for newborns occurred in 18 patients among 600,000 tested in this study. The authors recommend follow-up studies to determine the reproducibility of these results.

PubMed citation

Available at

Related Resources From the Same Author(s)

Patient safety and collaboration of the intensive care unit team.

April 22, 2009

Quality improvement implementation and hospital performance on patient safety indicators.

January 31, 2006

Patient safety climate in US hospitals: variation by management level.

November 12, 2008

Unintentionally retained foreign objects: a descriptive study of 308 sentinel events and contributing factors.

November 28, 2018

Relationship of safety climate and safety performance in hospitals.

April 1, 2009

Patterns of nurse–physician communication and agreement on the plan of care.

June 9, 2010

Impact of including readmissions for qualifying events in the Patient Safety Indicators.

April 22, 2015

Quiet please! Drug round tabards: are they effective and accepted? A mixed method study.

July 9, 2014

Patient safety climate in 92 US hospitals: differences by work area and discipline.

February 4, 2009

Detection of patient risk by nurses: a theoretical framework.

February 17, 2010

Workforce perceptions of hospital safety culture: development and validation of the patient safety climate in healthcare organizations survey.

September 26, 2007

Patient safety culture as a space of social struggle: understanding infection prevention practice and patient safety culture within hospital isolation settings - a qualitative study.

December 14, 2022

Bedside shift report improves patient safety and nurse accountability.

July 28, 2010

Unintentionally retained guidewires: a descriptive study of 73 sentinel events.

March 20, 2019

Ottawa Hospital Patient Safety Study: incidence and timing of adverse events in patients admitted to a Canadian teaching hospital.

March 6, 2005

Design and implementation of an application and associated services to support interdisciplinary medication reconciliation efforts at an integrated healthcare delivery network.

December 6, 2006

Frequency of inappropriate medical exceptions to quality measures.

March 31, 2010

Instrument readiness: an important link to patient safety.

January 19, 2011

Workplace violence and its effects on patient safety.

January 5, 2011

The normalization of deviance: what are the perioperative risks?

June 15, 2011

Evaluating the effectiveness of health care teams.

May 18, 2005

Burnout and medical errors among American surgeons.

December 9, 2009

The effect on medication errors of pharmacists charting medication in an emergency department.

December 17, 2008

Patient safety systems in the primary health care of diabetes—a story of missed opportunities?

November 17, 2010

How best to measure surgical quality? Comparison of the Agency for Healthcare Research and Quality Patient Safety Indicators (AHRQ-PSI) and the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) postoperative adverse events at a single institution.

September 28, 2011

Risk-sensitive events during laparoscopic cholecystectomy: the influence of the integrated operating room and a preoperative checklist tool.

March 3, 2010

Incidence and method of suicide in hospitals in the United States.

October 31, 2018

Translating patient safety legislation into health care practice.

November 29, 2006

Management of test results in family medicine offices.

July 29, 2009

Association of pediatric resident physician depression and burnout with harmful medical errors on inpatient services.

August 14, 2019

Identifying organizational cultures that promote patient safety.

November 18, 2009

Impact of online education on intern behaviour around Joint Commission national patient safety goals: a randomised trial.

June 27, 2012

Patient safety incidents associated with obesity: a review of reports to the National Patient Safety Agency and recommendations for hospital practice.

August 17, 2011

Evaluating situation awareness: an integrative review.

May 10, 2017

Health professionals' perspectives of safety issues in mental health services: a qualitative study.

March 31, 2021

A qualitative exploration of mental health service user and carer perspectives on safety issues in UK mental health services.

August 5, 2020

Reported clinical incidents of children with intellectual disability: a qualitative analysis.

June 15, 2022

The Johns Hopkins Hospital: identifying and addressing risks and safety issues.

March 6, 2005

Risk models to improve safety of dispensing high-alert medications in community pharmacies.

November 7, 2012

How will it work? A qualitative study of strategic stakeholders' accounts of a patient safety initiative.

March 10, 2010

Iatrogenic harm caused by diagnostic errors in fibrodysplasia ossificans progressiva.

November 23, 2005

Adverse drug event detection in pediatric oncology and hematology patients: using medication triggers to identify patient harm in a specialized pediatric patient population.

May 14, 2014

Patient safety vulnerabilities for children with intellectual disability in hospital: a systematic review and narrative synthesis.

April 25, 2018

Cluster randomized trial to evaluate the impact of team training on surgical outcomes.

October 5, 2016

Active surveillance using electronic triggers to detect adverse events in hospitalized patients.

June 14, 2006

Evaluation of organizational culture among different levels of healthcare staff participating in the Institute for Healthcare Improvement's 100,000 Lives Campaign.

February 29, 2012

Risk factors for retained instruments and sponges after surgery.

March 6, 2005

A prospective, multicenter study of pharmacist activities resulting in medication error interception in the emergency department.

February 1, 2012

Physician task load and the risk of burnout among US physicians in a national survey.

December 2, 2020

Team-based care: the changing face of cardiothoracic surgery.

October 11, 2017

Participation in EHR based simulation improves recognition of patient safety issues.

December 10, 2014

Cognitive errors detected in anaesthesiology: a literature review and pilot study.

January 25, 2012

Hospitalized patients' participation and its impact on quality of care and patient safety.

January 30, 2005

Special report: suicidal ideation among American surgeons.

February 2, 2011

Improved safety culture and teamwork climate are associated with decreases in patient harm and hospital mortality across a hospital system.

January 27, 2016

Change‐of‐shift nursing handoff interruptions: implications for evidence‐based practice.

November 6, 2019

ASHP guidelines: minimum standard for ambulatory care pharmacy practice.

July 22, 2015

Inadequate health literacy among paid caregivers of seniors.

January 30, 2005

Assessing teamwork attitudes in healthcare: development of the TeamSTEPPS teamwork attitudes questionnaire.

October 6, 2010

To what extent are patients involved in researching safety in acute mental healthcare?

April 6, 2022

Improving team information sharing with a structured call-out in anaesthetic emergencies: a randomized controlled trial.

March 12, 2014

Use of a safety climate questionnaire in UK health care: factor structure, reliability and usability.

November 22, 2006

Measuring adverse events in hospitalized patients: an administrative method for measuring harm.

September 7, 2016

The story behind the story: physician skepticism about relying on clinical information technologies to reduce medical errors.

December 19, 2007

A reduction in cardiac arrests and duration of clinical instability after implementation of a paediatric rapid response system.

December 16, 2009

Addressing physician burnout: the way forward.

February 22, 2017

Inappropriate preinjury warfarin use in trauma patients: a call for a safety initiative.

May 18, 2016

Impact of contact isolation for multidrug-resistant organisms on the occurrence of medical errors and adverse events.

October 23, 2013

Internally-developed online adverse drug reaction and medication error reporting systems.

June 7, 2006

Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014.

January 13, 2016

The role for leaders of health care organizations in patient safety.

September 19, 2007

Development and measurement of perioperative patient safety indicators.

March 18, 2015

Assessing patient safety culture in hospitals across countries.

May 15, 2013

Feedback from incident reporting: information and action to improve patient safety.

March 11, 2009

Rapid response teams and failure to rescue: one community's experience.

June 27, 2012

Improving accuracy of handoff by implementing an electronic health record-generated tool: an improvement project in an academic neonatal intensive care unit.

October 21, 2020

Accident analysis of large-scale technological disasters applied to an anaesthetic complication.

March 6, 2005

Systems approach to reduce errors in surgery.

August 3, 2005

Errors, incidents and accidents in anaesthetic practice.

March 6, 2005

Mandatory reporting of impaired medical practitioners: protecting patients, supporting practitioners.

February 4, 2015

Medication reconciliation in ambulatory care: attempts at improvement.

October 28, 2009

Measuring patient safety climate: a review of surveys.

October 12, 2005

Medication-error reporting and pharmacy resident experience during implementation of computerized prescriber order entry.

March 14, 2007

A piece of my mind. The art of constructive worrying.

June 20, 2018

Diagnostic errors in primary care: lessons learned.

February 22, 2012

Use of a standardized protocol to decrease medication errors and adverse events related to sliding scale insulin.

April 12, 2006

Learning from every death.

March 5, 2014

Patient reports of preventable problems and harms in primary health care.

March 6, 2005

Patient safety features of clinical computer systems: questionnaire survey of GP views.

June 29, 2005

A review of verbal order policies in acute care hospitals.

January 18, 2012

Association between concurrent use of prescription opioids and benzodiazepines and overdose: retrospective analysis.

May 17, 2017

Changes in burnout and satisfaction with work-life integration in physicians over the first 2 years of the COVID-19 pandemic.

October 26, 2022

Infusing fun into quality and safety initiatives.

January 30, 2013

Development and evaluation of a required patient safety course.

September 3, 2008

An intervention to decrease catheter-related bloodstream infections in the ICU.

January 3, 2007

Microsystems in health care: Part 2. Creating a rich information environment.

March 6, 2005

Direct reporting of laboratory test results to patients by mail to enhance patient safety.

July 26, 2006

Improving the accuracy of patient identification in the medication-use process.

February 8, 2006

The culture of safety: results of an organization-wide survey in 15 California hospitals.

March 6, 2005

Supporting doctors as healthcare quality and safety advocates: recommendations from the Association of Surgeons in Training (ASiT).

July 25, 2018

Related Resources

Assessing the clinical, economic, and health resource utilization impacts of prefilled syringes versus conventional medication administration methods: results from a systematic literature review.

December 13, 2023

WebM&M Cases

Delay in Malignancy Diagnosis Reflects Systemic Failures

October 31, 2023

Intraoperative communications between pathologists and surgeons: do we understand each other?

September 6, 2023

Clinical pathway adherence and missed diagnostic opportunities among children with musculoskeletal infections.

September 6, 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

WebM&M Cases

Missed Diagnosis of Addison’s Disease in Adolescent Presenting with Fatigue.

March 29, 2023

WebM&M Cases

Hospital-Acquired Diabetic Ketoacidosis.

February 1, 2023

Are pathologists self-aware of their diagnostic accuracy? Metacognition and the diagnostic process in pathology.

October 5, 2022

Machine learning models outperform manual result review for the identification of wrong blood in tube errors in complete blood count results.

June 29, 2022

Collaborative case review: a systems-based approach to patient safety event investigation and analysis.

March 30, 2022

Communicating certainty in pathology reports: interpretation differences among staff pathologists, clinicians, and residents in a multicenter study.

December 22, 2021

Adverse glycemic events and critical emergencies.

December 15, 2021

Clinical and financial implications of second-opinion surgical pathology review.

April 7, 2021

Outpatient insulin-related adverse events due to mix-up errors: findings from two national surveillance systems, United States, 2012-2017.

March 24, 2021

Potential preanalytical and analytical vulnerabilities in the laboratory diagnosis of coronavirus disease 2019 (COVID-19).

April 29, 2020

Error Reduction and Prevention in Surgical Pathology, Second Edition.

August 28, 2019

Hidden health IT hazards: a qualitative analysis of clinically meaningful documentation discrepancies at transfer out of the pediatric intensive care unit.

August 28, 2019

Measuring the rate of manual transcription error in outpatient point-of-care testing.

March 13, 2019

Insulin pumps have most reported problems in FDA database.

December 5, 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

Delayed Diagnosis of Endocrinologic Emergencies

November 1, 2017

Risk factors of missed colorectal lesions after colonoscopy.

September 6, 2017

Blood bank specimen mislabeling: a College of American Pathologists Q-Probes study of 41,333 blood bank specimens in 30 institutions.

June 7, 2017

WebM&M Cases

Hemolysis Holdup

May 1, 2017

Interpretive error in radiology.

March 1, 2017

Towards a new paradigm in laboratory medicine: the five rights.

December 21, 2016

See More About The Topic

Clinical Technologists

Physicians

Endocrinology

Pathology and Laboratory Medicine

Pediatric Endocrinology

Finding blunders in thyroid testing: experience in newborns.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Finding blunders in thyroid testing: experience in newborns.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

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