Among 2644 patients discharged over the 5-month
study period, we discovered only 15 results returning after discharge that were considered urgent by clinicians (the clinicians were unaware of 8 of these) and 35 results returning after discharge that changed the patient’s diagnostic or therapeutic plan (the clinicians were unaware of 24 of these). Despite these small numbers, the implications for patient safety remain impressive: Almost half of all discharged patients had pending test results, 6% of these patients had results considered potentially actionable by a
physician-reviewer, and physician awareness of these results was low. Failure to follow up on certain results (for example , the results of blood cultures) could have catastrophic consequences, but even results that do not require urgent action (such as discovery of a pulmonary nodule or iron deficiency) could have important consequences if overlooked. Given the high volume of results returning after discharge and the potential for patient harm if even a few
Among 2644 patients discharged over the 5-month
study period, we discovered only 15 results returning after discharge that were considered urgent by clinicians (the clinicians were unaware of 8 of these) and 35 results returning after discharge that changed the patient’s diagnostic or therapeutic plan (the clinicians were unaware of 24 of these). Despite these small numbers, the implications for patient safety remain impressive: Almost half of all discharged patients had pending test results, 6% of these patients had results considered potentially actionable by a
physician-reviewer, and physician awareness of these results was low. Failure to follow up on certain results (for example , the results of blood cultures) could have catastrophic consequences, but even results that do not require urgent action (such as discovery of a pulmonary nodule or iron deficiency) could have important consequences if overlooked. Given the high volume of results returning after discharge and the potential for patient harm if even a few
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