U.S. Department of Health & Human Services
Pathology & Laboratory Medicine
PATIENT SAFETY PRIMERS
2014 ANNUAL PERSPECTIVES
Device-related Complications (1)
Diagnostic Errors (72)
Identification Errors (38)
Discontinuities, Gaps, and Hand-Off Problems (58)
Medication Safety (14)
Medical Complications (4)
Nonsurgical Procedural Complications (3)
Surgical Complications (5)
Transfusion Complications (11)
Psychological and Social Complications (8)
Australia and New Zealand (5)
Central and South America (2)
North America (133)
Journal Article (148)
Newspaper/Magazine Article (10)
Special or Theme Issue (4)
Web Resource (3)
Epidemiology of Errors and Adverse Events (54)
Active Errors (58)
Latent Errors (20)
Near Miss (3)
Approach to Improving Safety
Quality Improvement Strategies (51)
Legal and Policy Approaches (12)
Error Reporting and Analysis (58)
Communication Improvement (33)
Human Factors Engineering (18)
Specialization of Care (3)
Logistical Approaches (38)
Culture of Safety (5)
Technologic Approaches (37)
Education and Training (19)
Pathology & Laboratory Medicine
Health Care Providers (130)
Health Care Executives and Administrators (109)
Non-Health Care Professionals (42)
Setting of Care
Ambulatory Care (20)
Outpatient Surgery (1)
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Failure to follow-up test results for ambulatory patients: a systematic review.
Callen JL, Westbrook JI, Georgiou A, Li J. J Gen Intern Med. 2012;27:1334-1348.
The safety implications of missed test results for hospitalised patients: a systematic review.
Callen J, Georgiou A, Li J, Westbrook JI. BMJ Qual Saf 2011;20:194-199.
Notification of abnormal lab test results in an electronic medical record: do any safety concerns remain?
Singh H, Thomas EJ, Sittig DF, et al. Am J Med. 2010;123:238-244.
A randomized trial of electronic clinical reminders to improve medication laboratory monitoring.
Matheny ME, Sequist TD, Seger AC, et al. J Am Med Inform Assoc. 2008;15:424-429.
Errors in laboratory medicine: practical lessons to improve patient safety.
Howanitz PJ. Arch Pathol Lab Med. 2005;129:1252-1261.
The attributes of medical event reporting systems.
Battles JB, Kaplan HS, Van der Scaaf TW, Shea CE. Arch Pathol Lab Med. 1998;1222:231-238.
Changes in rates of autopsy-detected diagnostic errors over time: a systematic review.
Shojania KG, Burton EC, McDonald KM, Goldman L. JAMA. 2003;289:2849-2856.
Clinical impact and frequency of anatomic pathology errors in cancer diagnoses.
Raab SS, Grzybicki DM, Janosky JE, et al. Cancer. 2005;104:2205-2213.
Diagnostic concordance among pathologists interpreting breast biopsy specimens.
Elmore JG, Longton GM, Carney PA, et al. JAMA. 2015;313:1122-1132.
Root cause analysis reports help identify common factors in delayed diagnosis and treatment of outpatients.
Davis Giardina T, King BJ, Ignaczak AP, et al. Health Aff (Millwood). 2013;32:1368-1375.
Outside case review of surgical pathology for referred patients: the impact on patient care.
Swapp RE, Aubry MC, Salomão DR, Cheville JC. Arch Pathol Lab Med. 2013;137:233-240.
Look back and talk openly: responding to and communicating about the risk of large-scale error in pathology diagnoses.
Aldrich R, Finlayson P, Hill K, Sullivan M. Int J Qual Health Care. 2012;24:135-143.
Design and implementation of an automated email notification system for results of tests pending at discharge.
Dalal AK, Schnipper JL, Poon EG, et al. J Am Med Inform Assoc. 2012;19:523-538.
Voluntary electronic reporting of laboratory errors: an analysis of 37,532 laboratory event reports from 30 health care organizations.
Snydman LK, Harubin B, Kumar S, Chen J, Lopez RE, Salem DN. Am J Med Qual. 2012;27:147-153.
Impact of health information technology interventions to improve medication laboratory monitoring for ambulatory patients: a systematic review.
Fischer SH, Tjia J, Field TS. J Am Med Inform Assoc. 2010;17:631-636.
Frequency of failure to inform patients of clinically significant outpatient test results.
Casalino LP, Dunham D, Chin MH, et al. Arch Intern Med. 2009;169:1123-1129.
The impact of clinically undiagnosed injuries on survival estimates.
Gedeborg R, Thiblin I, Byberg L, Wernroth L, Michaëlsson K. Crit Care Med. 2009;37:449-455.
The Final Check: Say it Out Loud.
Plano, TX: Outcome Engenuity; July 2012.
Frequency and outcome of cervical cancer prevention failures in the United States.
Raab SS, Grzybicki DM, Zarbo RJ, et al. Am J Clin Pathol. 2007;128:817-824.
Development and validation of electronic health record–based triggers to detect delays in follow-up of abnormal lung imaging findings.
Murphy DR, Thomas EJ, Meyer AND, Singh H. Radiology. 2015 May 11; [Epub ahead of print].
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