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Patient Safety Concerns Arising from Test Results That Return after Hospital Discharge

Christopher L. Roy, MD; Eric G. Poon, MD, MPH; Andrew S. Karson, MD, MPH; Zahra Ladak-Merchant, BDS, MPH; Robin E. Johnson, BA; Saverio M. Maviglia, MD, MSc; and Tejal K. Gandhi, MD, MPH
[+] Article, Author, and Disclosure Information

From Brigham and Women's Hospital and Massachusetts General Hospital, Boston, Massachusetts.

Acknowledgments: The authors thank Mr. Justin Golden and Mr. Martin Spera.

Grant Support: By a grant from the Harvard Risk Management Foundation, Cambridge, Massachusetts.

Potential Conflicts of Interest: None disclosed.

Requests for Single Reprints: Christopher L. Roy, MD, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115; e-mail, croy@partners.org.

Current Author Addresses: Drs. Roy and Maviglia: Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115.

Drs. Poon and Gandhi, Ms. Ladak-Merchant, and Ms. Johnson: Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA 02120.

Dr. Karson: Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114.

Ann Intern Med. 2005;143(2):121-128. doi:10.7326/0003-4819-143-2-200507190-00011
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We carried out our study on the general medicine hospitalist services at 2 academic tertiary care centers in Boston, Massachusetts (hospitals A and B). The human research committee for both hospitals reviewed and approved the study design. The hospitals belong to the same integrated care-delivery network and share a common electronic clinical data repository that includes test results, discharge orders and summaries, ambulatory notes, and medication and problem lists. These data are accessible at all inpatient and outpatient sites through the same electronic medical record. In addition, all physicians use the same e-mail system.

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Grahic Jump Location
Figure 1.
Identifying results for physician review
Grahic Jump Location
Grahic Jump Location
Figure 2.
Identification of potentially actionable postdischarge results
Grahic Jump Location




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The Duty to Follow up on Ordered Tests
Posted on August 4, 2005
Lars H Lund
Karooinska University Hospital, Division of Cardiology
Conflict of Interest: None Declared

In response to the alarming Institute of Medicine report that between 44,000 and 98,000 patiens die in US hosptials as a result of medical error (http://www4.nationalacademies.org/news.nsf/isbn/0309068371?OpenDocument, accessed 2005), physicians may be becoming more focused on errors of commission. However, in light of the remarkable advances over recent decades in the ability to prevent, detect, and treat disease, we must not forget errors of omission. One blatant and avoidable such error is to fail to follow up on and treat abnormal test results that return after hospital discharge, which Roy et al. show occurs frequently (Roy et al. Ann Intern Med 2005;143 121-128). It is every physicians personal responsibility to follow up on and address tests that he or she orders!

Conflict of Interest:

None declared

Follow-up of Tests Returned after Discharge of Hospitalized Patients
Posted on September 5, 2005
Martin M. Grajower
Albert Einstein College of Medicine
Conflict of Interest: None Declared

The high percentage of test results that are reported after a patient's discharge from the hospital, with the corresponding significant number of "actionable" abnormalities, as documented by Roy, et. al. (Ann Intern Med 2005; 143: 121-128), correctly lead the authors to recommend better follow-up systems for test results returning after hospital discharge.

When I was an endocrine fellow back in 1976-77, I almost always had to follow-up on endocrine tests ordered on in-patient consultations that returned following their discharge. I had an index card on each patient I saw and listed all tests I had requested. Once or twice a week I checked the lab computer for these results. No card was filed away until all results were obtained. Each card had contact information (either for the patient directly or the primary physician) for me to be able to follow-up on abnormals.

I would propose a concept that house officers in particular may find outlandish: any physician that orders any laboratory test on any patient should be responsible for obtaining the results of that test. Keeping some "file" system, either with pen or stylus, should be de riguer (as it still is for me). For "routine" tests (thyroid function tests, cultures, electrolytes, etc.) this could indeed be burdensome. I would therefore propose that each hospital have a system whereby the laboratory itself, or a unit secretary on the ward, forward any test result on a discharged patient to the ordering physician "“ either by email or postal mail (which of course presumes that every test that arrives in any laboratory, have the name of the ordering physician). The burden would then be on the ordering physician to follow-up on the abnormals. For the attending MD's, sending the results to them would entail doing what they already do routinely on in-office patients "“ follow up on test results that always arrive after the patient has "left" "“ but with the convenience of the results being delivered to the MD, as they are with in-office patients.

For house officers, it would be another aspect of their education: following up on patients no longer physically in their presence. It might also make them think just a second longer before ordering any tests "“ knowing that every check box on a lab slip will entail follow-up work. With a little luck, it might thereby also reduce the number of unnecessary tests ordered on in-patients. Now there's a novel idea!

Conflict of Interest:

None declared

Initiatives to Follow-up on Test Results that Return After Discharge
Posted on November 16, 2005
Andrew P. Modest
Harvard Vanguard Medical Associates, Mount Auburn Hospital
Conflict of Interest: None Declared


We read with great interest the study by Roy and colleagues in the July 19, 2005 issue that elucidates patient safety concerns arising from test results that return after a patient is discharged from the hospital. This issue is particularly acute in hospitals with a large percentage of patients under the care of Hospitalists. We are implementing the following enhancements to our discharge process to address this underappreciated, prevalent and serious problem.

We have devised a "One Touch" feature in our clinical information system that will instantly present a list at the time of discharge of all lab and test results (including radiology, cardiology and pathology) that are pending or not yet finalized. This list can be forwarded to the Primary Care Physician at the time of discharge.

Another solution is for test results that are reported or finalized after discharge to be printed on a unique hash-marked paper, so that all parties who receive these results (Attendings, Primary Care Physicians, Consultants) can readily identify that these are new, un-reviewed results.

Another initiative of our re-engineering discharge process is a pilot of the "Discharge Time Out." Analogous to the "Preoperative Time Out" used by surgical teams at the start of a case, the "Discharge Time Out" is a team meeting led by the Attending to reflect on the care given and provide additional teaching. The team identifies the principal and secondary diagnoses, which improves the accuracy of discharge summaries and subsequent coding on which performance indicators and billing activities are based. Medication Reconciliation is performed, and significant test results are reviewed. Key unresolved clinical issues are highlighted for communication to the Primary Care Physician. At this stage in our pilot, the process goes smoothly, takes less than 15 minutes, and has been enthusiastically received.

Conflict of Interest:

None declared

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