Although timely follow-up on test results has received
attention from the Agency for Healthcare Research and
Quality (8) and failure to follow up on results has been
recognized by a large malpractice insurer (9) as accounting for one quarter of diagnosis-related malpractice cases, few studies have addressed follow-up on test results pending at hospital discharge. Moore and colleagues (7) studied test follow-up errors, which were defined as having a test result noted as pending at discharge in the inpatient medica record but not acknowledged in the outpatient chart. Using retrospective chart review, they found this type of error
in the records of 8% of all discharged patients and 41% of all patients discharged with pending test results, but their study design did not allow them to determine 1) whether clinicians were aware of the results and did not document them or 2) the clinical consequences of these errors. To our knowledge, no other studies have prospectively examined the prevalence and characteristics of test results that return after discharge or physician awareness of them. We hypothesized that test results pending at discharge are frequently overlooked in the handoff from the inpatient
physician to the outpatient physician and that some of
these results might have important clinical consequences for patients. Accordingly, we sought to prospectively determine the prevalence and characteristics of these potentially actionable results, to determine how often physicians are unaware of these results, and to evaluate the satisfaction of inpatient physicians with current systems for following up
on results returning after discharge
Although timely follow-up on test results has received
attention from the Agency for Healthcare Research and
Quality (8) and failure to follow up on results has been
recognized by a large malpractice insurer (9) as accounting for one quarter of diagnosis-related malpractice cases, few studies have addressed follow-up on test results pending at hospital discharge. Moore and colleagues (7) studied test follow-up errors, which were defined as having a test result noted as pending at discharge in the inpatient medica record but not acknowledged in the outpatient chart. Using retrospective chart review, they found this type of error
in the records of 8% of all discharged patients and 41% of all patients discharged with pending test results, but their study design did not allow them to determine 1) whether clinicians were aware of the results and did not document them or 2) the clinical consequences of these errors. To our knowledge, no other studies have prospectively examined the prevalence and characteristics of test results that return after discharge or physician awareness of them. We hypothesized that test results pending at discharge are frequently overlooked in the handoff from the inpatient
physician to the outpatient physician and that some of
these results might have important clinical consequences for patients. Accordingly, we sought to prospectively determine the prevalence and characteristics of these potentially actionable results, to determine how often physicians are unaware of these results, and to evaluate the satisfaction of inpatient physicians with current systems for following up
on results returning after discharge
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