U.S. Department of Health & Human Services
Pathology & Laboratory Medicine
PATIENT SAFETY PRIMERS
Device-related Complications (1)
Diagnostic Errors (68)
Identification Errors (36)
Discontinuities, Gaps, and Hand-Off Problems (53)
Medication Safety (14)
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Surgical Complications (5)
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Journal Article (141)
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Epidemiology of Errors and Adverse Events (50)
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Approach to Improving Safety
Quality Improvement Strategies (50)
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Error Reporting and Analysis (55)
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Pathology & Laboratory Medicine
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Setting of Care
Ambulatory Care (19)
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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.
Clinical impact and frequency of anatomic pathology errors in cancer diagnoses.
Raab SS, Grzybicki DM, Janosky JE, et al. Cancer. 2005;104:2205-2213.
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.
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.
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.
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.
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.
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.
The frequency of missed test results and associated treatment delays in a highly computerized health system.
Wahls TL, Cram PM. BMC Fam Pract. 2007;8:32.
Surgical specimen identification errors: a new measure of quality in surgical care.
Makary MA, Epstein J, Pronovost PJ, Millman EA, Hartmann EC, Freischlag JA. Surgery. 2007;141:450-455.
The Final Check: Say it Out Loud.
Plano, TX: Outcome Engenuity; July 2012.
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