Medical Error Prevention: Patient Safety

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Author: Garland E. Pendergraph, PhD, JD, MLS(ASCP)SM, HCLD/CC(ABB)
Reviewer: Julie Ann West, PhD, MLS(ASCP)CM, SM(ASCP)CM

Medical Error Prevention is a comprehensive course that includes potential causes of medical errors in the clinical laboratory, important legislation and definitions, and steps laboratorians can take to reduce the impact of medical errors in their workplace. This course is an ideal part of an effective medical error reduction program and is appropriate for both experienced and novice laboratorians.

Continuing Education Credits


  • List and describe the six aims of the National Academy of Medicine (NAM) - formerly called the Institute of Medicine (IOM) - to improve health care quality.
  • Describe the NAM (IOM) aims within the context of quality clinical laboratory services.
  • Define "total testing process" and recognize problems (errors) that could occur in each phase of the total testing process.
  • Identify outcomes of patient safety errors with respect to clinical laboratory services.
  • Discuss patient safety goals.

Course Outline

  • Six Aims of the National Academy of Medicine (NAM) to Improve the Quality of Healthcare
      • State of Quality in Healthcare
      • Six Domains of Quality in Healthcare as Defined by the National Academy of Medicine (NAM)
      • Improving Effectiveness
      • Patient-centered Care and Timeliness
      • Preventing Medical Errors Through Patient Involvement
      • Efficiency and Equity
      • According to the National Academy of Medicine (NAM), quality health care systems in the United States should be:
      • One way patients and their families can become active participants in their healthcare is by:
  • The National Academy of Medicine (NAM) Aims Within the Context of Quality Clinical Laboratory Services
      • Clinical Laboratory Services and Safety
      • How might patient harm result from each of these problems related to clinical laboratory services? Consider your answer and then click on the defined ...
      • Clinical Laboratory Services and Effectiveness
      • Clinical Laboratory Services and Patient-centered Care
      • Clinical Laboratory Services and Timeliness
      • Clinical Laboratory Services and Efficiency
      • Clinical Laboratory Services and Equity
      • Which of the following best defines "effective clinical laboratory services?"
      • How might a laboratory ensure equity in laboratory testing services?
  • Recognizing Problems (Errors) that Could Occur in Each Phase of the Total Testing Process
      • Medical Errors
      • How might the following factors contribute to medical errors? Consider your answer and then click on the defined problem to reveal the potentially har...
      • Total Testing Process
      • Safe Preanalytical Component of Total Testing Process
      • Safe Analytical Component of Total Testing Process
      • Safe Post-analytical Component of Total Testing Process
      • Patient-Centered Preanalytical Component of Total Testing Process
      • Patient-Centered Analytical Component of Total Testing Process
      • Patient-Centered Post-analytical Component of Total Testing Process
      • Identify the phase of the total testing process in which each error occurs.
      • Misinterpretation of an alphabetic flag in the result field - using a lowercase letter L (l) to indicate "low result", where the result could be inter...
  • Outcomes of Patient Safety Errors with Respect to Clinical Laboratory Services
      • Outcomes of Laboratory Services
      • The Laboratory Quality Management System and Non-Conforming Events (NCEs)
      • Reportable Errors
      • Reporting of Errors
      • NCEs of External Origin
      • NCEs of Internal Origin
      • Root Cause Analysis (RCA)
      • Root Cause Analysis (RCA), continued
      • Management of Non-Conforming Events (NCEs)
      • RCA Example: Cause-and-Effect Diagram
      • Failure Mode and Effect Analysis (FMEA)
      • Five Whys
      • A patient event occurs that results in a "near miss" (an event that was averted but may have resulted in death or serious injury). The error was caugh...
      • Nonconforming events (NCEs) may be of external or internal origin. From the answer choices, choose the NCE of internal origin:
  • Sources of Data to Identify Errors and Patient Outcomes
      • Monitoring Laboratory Processes to Prevent Medical Errors
      • Data Sources to Identify Errors
      • All of these sources may be useful for identifying patient safety problems, except:
  • Patient Safety Goals
      • The Joint Commission National Patient Safety Goals 2023 for Clinical Laboratories
      • National Patient Safety Goal: Identify Patients Correctly
      • Which of the following is not an acceptable patient identifier to use prior to performing venipuncture procedures?
      • National Patient Safety Goal: Improve Staff Communication
      • National Patient Safety Goal: Prevent Infection Through Hand Hygiene
      • What is generally considered the single most important procedure for preventing the spread of nosocomial (hospital-acquired) infection?
  • References
      • References

Additional Information

Level of Instruction: Intermediate
Intended Audience: Medical laboratory professionals
Author: Garland E. Pendergraph, PhD, JD, MLS(ASCP)SM, HCLD/CC(ABB) received his MSPH from the University of Kentucky in Lexington, his PhD in medical parasitology/entomology and mycology from the University of North Carolina in Chapel Hill and his law degree with a concentration in health care law from Concord Law School, Purdue University. He also did a Fellowship in Tropical Medicine at Louisiana State University School of Medicine. He is the author of a textbook on phlebotomy, a number of scientific articles, plus internet training programs. He is the director of five laboratories.
Reviewer: Dr. Julie Ann West is certified by the American Society for Clinical Pathology (ASCP) as a Medical Laboratory Scientist (MLS) and as a Specialist in Microbiology (SM). In addition, Dr. West has earned a PhD in Public Health - Epidemiology Specialization (emphasis on infectious diseases) - and is Certified in Public Health (CPH) by the National Board of Public Health Examiners. Dr. West is experienced as a Technical Specialist, Safety Officer, Educator, and Lead in the Veterans Administration Healthcare System, and has prior experience as an Administrative Laboratory Director.

This course is part of:
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