The Laboratory and Patient Safety

Clinics in Laboratory Medicine

Volumn 27, Issue 4, 2007, Pages 909-930

  Wagar, Elizabeth A ^a   Yuan, Shan ^a  

^a UNIVERSITY OF CALIFORNIA   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ACCURACY; CLINICAL LABORATORY; HEALTH CARE COST; HEALTH CARE DELIVERY; MEDICAL ERROR; PATIENT CARE; PATIENT IDENTIFICATION; PATIENT SAFETY; PRIORITY JOURNAL; REVIEW; TOTAL QUALITY MANAGEMENT;

HUMANS; LABORATORY TECHNIQUES AND PROCEDURES; MEDICAL ERRORS; PATHOLOGY, CLINICAL; PATIENT CARE; PATIENTS; QUALITY ASSURANCE, HEALTH CARE; SAFETY MANAGEMENT;

EID: 35348827287     PISSN: 02722712     EISSN: None     Source Type: Journal    
DOI: 10.1016/j.cll.2007.07.002     Document Type: Review

References (64)

1. Institute of Medicine. To err is human: building a safer health system (2000), National Academy Press, Washington, DC
2. Brennan T.A., Leape L.L., Laird N.M., et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study. N Engl J Med 324 6 (1991) 370-376
3. Leape L.L., Brennan T.A., Laird N.M., et al. The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study, II. N Engl J Med 324 6 (1991) 377-384
4. Thomas E.J., Studdert D.M., Burstin H.R., et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care 38 3 (2000) 261-271
5. Occupational Safety and Health Administration. The new OSHA: reinventing worker safety and health. Available at: http://www.osha.gov/doc/outreachtraining/htmlfiles/newosha.html. Accessed August 23, 2007.
6. Phillips D.P., Christenfeld N., and Glynn L.M. Increase in U.S. medication-error deaths between 1983 and 1993. Lancet 351 9103 (1998) 643-644
7. Institute of Medicine. Crossing the quality chasm (2001), National Academy Press, Washington, DC
8. Weissman J.S., Rothschild J.M., Bendavid E., et al. Hospital workload and adverse events. Med Care 45 5 (2007) 448-455
9. Smith, S. Making the laboratory a key partner in patient safety. Presented at the Quality Institute conference. Atlanta, April 13-15, 2003.
10. Howanitz P.J. Errors in laboratory medicine: practical lessons to improve patient safety. Arch Pathol Lab Med 129 10 (2005) 1252-1261
11. Howanitz P.J., Renner S.W., and Walsh M.K. Continuous wristband monitoring over 2 years decreases identification errors: a College of American Pathologists Q-Tracks study. Arch Pathol Lab Med 126 7 (2002) 809-815
12. Zarbo R.J., Jones B.A., Friedberg R.C., et al. Q-Tracks; a College of American Pathologists program of continuous laboratory monitoring and longitudinal tracking. Arch Pathol Lab Med 126 9 (2002) 1036-1044
13. Bonini P., Plebani M., Ceriotti F., et al. Errors in laboratory medicine. Clin Chem 48 5 (2002) 691-698
14. Plebani M. Errors in clinical laboratories or errors in laboratory medicine?. [review]. Clin Chem Lab Med 44 6 (2006) 750-759
15. Plebani M., and Carraro P. Mistakes in a stat laboratory; types and frequency. Clin Chem 43 8 Pt 1 (1997) 1348-1351
16. Astion M.L., Shojania K.G., Hamill T., et al. Classifying laboratory incident reports to identify problems that jeopardize patient safety. Am J Clin Pathol 120 1 (2003) 18-26
17. Editorial Staff. Root cause analysis and patient safety interventions. An interview with John Gosbee, MD. Laboratory Errors and Patient Safety 1 6 (2005) 5-8
18. Astion M.L. Putting power into patient safety interventions. Part I. Laboratory Errors and Patient Safety 1 6 (2005) 9-11
19. Astion M.L., Chou D., and Fine J.S. Clinically significant errors caused by misrepresentation of laboratory data in electronic medical record. Laboratory Errors and Patient Safety 1 5 (2005) 7-9
20. Koppel R., Metlay J.P., Cohen A., et al. Role of computerized physician order entry systems in facilitating medication errors. JAMA 293 10 (2005) 1197-1203
21. Merriam-Webster online dictionary. Available at: http://www.m-w.com. Accessed August 22, 2007.
22. Marx D. Patient safety and the "just culture": a primer for healthcare executives. April 2001. Available at: http://www.mers-tm.net/support/marx_primer.pdf. Accessed August 22, 2007.
23. Wang S., and Ho V. Corrections of clinical chemistry test results in a laboratory information system. Arch Pathol Lab Med 128 8 (2004) 890-892
24. Yuan S., Astion M.L., Shapiro J., et al. Clinical impact associated with corrected results in clinical microbiology testing. J Clin Microbiol 43 5 (2005) 2188-2193
25. Natividad C. Characterizing cases associated with corrected reports in hematology and coagulation. Presented at AACC Annual Meeting and Trade Expo. San Diego, July 15-9, 2007.
26. Szekendi M.K., Sullivan C., Bobb A., et al. Active surveillance using electronic triggers to detect adverse events in hospitalized patients. Qual Saf Health Care 15 3 (2006) 184-190
27. Shojania K.G., and Wald H. Incident reporting. In: Shojania K.G., Duncan B.W., Donald K.M., et al. (Eds). Making health care safer: a critical analysis of patient safety practices (2001), Agency for Healthcare Research and Quality, Rockville, MD 01-E058
28. Editorial staff. Incident reporting best practices. An interview with Dr. Kaveh Shojania. Laboratory Errors and Patient Safety 1 5 (2005) 4-6
29. Dixon J.F. Going paperless with custom-built Web-based patient occurrence reporting. Jt Comm J Qual Improv 28 7 (2002) 387-395
30. Mell L, Knelly S. Development of an integrated system for reporting, analyzing and learning from adverse incidents involving patients, staff and others. Presented at the IQLM Conference Poster Session. Atlanta, April 28-30, 2005.
31. Editorial staff. Online incident reporting. An interview with Dr. Mark A. Keroack. Laboratory Errors and Patient Safety 1 5 (2005) 7-9
32. Wagar E.A., Tamashiro L., Yasin B., et al. Patient safety in the clinical laboratory: a longitudinal analysis of specimen identification errors. Arch Pathol Lab Med 130 11 (2006) 1662-1668
33. Medical event reporting system-transfusion medicine: risk assessment index tool. Available at: http://www.mers-tm.net/. Accessed May 2, 2007.
34. Kaplan H.S. Getting the right blood to the right patient: the contribution of near-miss event reporting and barrier analysis. Transfus Clin Biol 12 5 (2005) 380-384
35. Department of Health. An organization with a memory (2000), Department of Health, London
36. Callum J.L., Merkley L.L., Coovadia A.S., et al. Experience with the medical event reporting system for transfusion medicine (MERS-TM) at three hospitals. Transfus Apher Sci 31 2 (2004) 133-143
37. Chassin M., and Becher E.C. The wrong patient. Ann Intern Med 136 11 (2002) 826-833
38. Conti N, Hardy G. Reducing laboratory specimen error with handheld technology. Presented at the Second Annual Summit on Patient Safety and Information Technology. Orlando, July 10-11, 2003.
39. Joint Commission on Accreditation of Healthcare Organizations. 2006 National Patient Safety Goals. Available at: http://www.jcipatientsafety.org. Accessed August 22, 2007.
40. Dock B. Improving the accuracy of specimen labeling. Clin Lab Sci 18 4 (2005) 210-212
41. BDid patient identification system. Available at: http://www.usa.siemens.com/index.jsp?sdc_p=fmlsuo1438629. Accessed August 22, 2007.
42. Editorial staff. Implementation of an automated identification and specimen collection system. An interview with Lawrence Bologna and Michael Mutter. Laboratory Errors and Patient Safety 2 2 (2005) 8-11
43. Bologna L.I., and Mutter M. Life after phlebotomy deployment; reducing major patient and specimen identification errors. J Healthc Inf Manag 16 1 (2002) 65-70
44. Wagar E.A., Raz M., and Yasin B. Patient safety partnership projects in the clinical laboratory. Am J Clin Pathol 126 Suppl. 1 (2006) S53-S60
45. Wagar EA, Friedberg RC, Souers R, et al. Critical values comparison: a College of American Pathologists Q-PROBES survey of 163 clinical laboratories. Arch Pathol Lab Med, in press.
46. Wagar E.A., Stankovic A.K., Wilkinson D.S., et al. Assessment monitoring of laboratory critical values: a College of American Pathologists Q-Tracks study of 180 institutions. Arch Pathol Lab Med 131 1 (2007) 44-49
47. Howanitz P.J., Steindel S.J., and Heard N.V. Laboratory critical values policies and procedures: a College of American Pathologists Q-Probes study in 623 institutions. Arch Pathol Lab Med 126 6 (2002) 663-669
48. Chou D. Integrating instruments and the laboratory information system. Am J Clin Pathol 105 4 Suppl 1 (1996) S60-S64
49. Barenfanger J., Sautter R.L., Lang D.L., et al. Improving patient safety by repeating (read-back) telephone reports of critical information. Am J Clin Pathol 121 6 (2004) 801-803
50. Under national patient safety goals. Available at: http://www.jointcommision.org. Accessed August 22, 2007.
51. Dighe A.S., Rao A., Coakley A.B., et al. Analysis of laboratory critical value reporting at a large academic medical center. Am J Clin Pathol 125 5 (2006) 758-764
52. Washbourn S., and Kay J.D. Cost and effects of telephoning clinically urgent reports. Clin Chim Acta 355 Suppl (2005) S396-S397
53. Vocada, fail safe communications. Available at: http://www.vocada.com. Accessed August 22, 2007.
54. Kuperman G.J., Teich J.M., Tanasijevic M.J., et al. Improving response to critical laboratory results with automation: results of a randomized controlled trial. J Am Med Inform Assoc 6 6 (1999) 512-522
55. Tate K.E., Gardner R.M., and Weaver L.K. A computerized laboratory alerting system. MD Comput 7 5 (1990) 296-301
56. In: Hurtado M.P., and Swift E.K. (Eds). Envisioning the National Health Care Quality Report. Institute of Medicine, Committee on the National Quality Report on Health Care Delivery. Washington, DC: National Quality Report on Health Care Delivery (2001), National Academy Press, Washington, DC
57. Poon E.G., Kuperman G.J., Fiskio J., et al. Real-time notification of laboratory data requested by users through alphanumeric pagers. J Am Med Inform Assoc 9 3 (2002) 217-222
58. Kay J.D., Nurse D., Bountis C., et al. The Oxford clinical intranet: providing clinicians with access to patient records and multiple knowledge bases with internet technology. Stud Health Technol Inform 100 (2004) 130-138
59. Laposata M.E., Laposata M., Vankott E.M., et al. Physician survey of a laboratory medicine interpretive service and evaluation of the influence of interpretations on laboratory test ordering. Arch Pathol Lab Med 128 12 (2004) 1424-1427
60. Dighe A.S., Soderberg B.L., and Laposata M. Narrative interpretations for clinical laboratory evaluations. Am J Clin Pathol 116 (2001) S123-S128
61. Macmillan D.H., Soderberg B.L., and Laposata M. Regulations regarding reflexive testing and narrative interpretations in laboratory medicine. Am J Clin Pathol 116 (2001) S129-S132
62. Laposata M. Patient-specific narrative interpretations of complex clinical laboratory evaluations: who is competent to provide them?. Clin Chem 50 3 (2004) 471-472
63. Lim E.M., Sikaris K.A., Gill J., et al. Quality assessment of interpretative commenting in clinical chemistry. Clin Chem 50 3 (2004) 632-637
64. Burroughs T.E., Waterman A.D., Gallagher T.H., et al. Patients concerns about medical errors during hospitalization. Jt Comm J Qual Patient Saf 33 1 (2007) 5-14