Pending studies at hospital discharge: a pre-post analysis of an electronic medical record tool to improve communication at hospital discharge.

Molly A. Kantor; Kambria H. Evans; Lisa Shieh

Study

Pending studies at hospital discharge: a pre-post analysis of an electronic medical record tool to improve communication at hospital discharge.

January 7, 2015

Kantor MA, Evans KH, Shieh L. J Gen Intern Med. 2015;30(3):312-8.

View more articles from the same authors.

In this single-site study, 70% of patients discharged from a general medicine service had at least one pending test result. The introduction of a tool that automatically generates a list of studies pending at discharge improved communication of pending studies from 18% to 43%.

PubMed citation

Available at

Related Resources From the Same Author(s)

Prevalence and characterisation of diagnostic error among 7-day all-cause hospital medicine readmissions: a retrospective cohort study.

September 16, 2020

Assigning a team-based pager for on-call physicians reduces paging errors in a large academic hospital.

February 12, 2014

Night-time communication at Stanford University Hospital: perceptions, reality and solutions.

November 15, 2017

Critical care checklists, the Keystone Project, and the Office for Human Research Protections: a case for streamlining the approval process in quality-improvement research.

January 28, 2009

Inadvertent administration of magnesium sulfate through the epidural catheter: report and analysis of a drug error.

January 18, 2006

Coworker abuse in healthcare: voices of mistreated workers.

March 15, 2023

Medication reconciliation in the emergency department: opportunities for workflow redesign.

December 15, 2010

Identifying critically ill patients at risk for inappropriate antibiotic therapy: a pilot study of a point-of-care decision support alert.

September 10, 2014

View the world through a different lens: shadowing another provider.

October 8, 2008

The hidden risk of wheelchair use.

September 28, 2022

Perioperative patient safety: correct patient, correct surgery, correct side--a multifaceted, cross-organizational, interventional study.

August 8, 2007

Assessing content validity and user perspectives on the Team Check-up Tool: expert survey and user focus groups.

April 5, 2017

Identification and characterization of failures in infectious agent transmission precaution practices in hospitals: a qualitative study.

June 20, 2018

Making communication and resolution programmes mission critical in healthcare organisations.

November 11, 2020

Detection and prevention of medication errors using real-time bedside nurse charting.

August 31, 2005

Getting by: underuse of interpreters by resident physicians.

January 28, 2009

Defining and measuring patient safety.

March 6, 2005

Policy and the future of adverse event detection using information technology.

March 6, 2005

Safety gaps in medical team communication: closing the loop on quality improvement efforts in the cardiac catheterization lab.

June 8, 2022

The impact of primary care providers' bias on depression screening for lesbian women.

August 2, 2023

Perinatal clinical decision support system: a documentation tool for patient safety.

October 10, 2007

Nurse staffing, burnout, and health care-associated infection.

August 15, 2012

Opioids prescribed after low-risk surgical procedures in the United States, 2004–2012.

December 7, 2016

Hospitalwide adverse drug events before and after limiting weekly work hours of medical residents to 80.

August 3, 2005

The Team Checkup Tool: evaluating QI team activities and giving feedback to senior leaders.

October 8, 2008

Developing process-support tools for patient safety: finding the balance between validity and feasibility.

October 8, 2008

Vital signs: trends in emergency department visits for suspected opioid overdoses- United States, July 2016- September 2017.

March 21, 2018

Statewide collaborative to reduce surgical site infections: results of the Hawaii Surgical Unit-Based Safety Program.

June 20, 2018

Controversy and quality improvement: lingering questions about ethics, oversight, and patient safety research.

May 28, 2008

Family participation during intensive care unit rounds: goals and expectations of parents and health care providers in a tertiary pediatric intensive care unit.

October 8, 2014

On the prospects for a blame-free medical culture.

November 4, 2009

Transforming the health care environment collaborative.

April 9, 2014

Identifying and categorising patient safety hazards in cardiovascular operating rooms using an interdisciplinary approach: a multisite study.

May 23, 2012

Risk factors for adverse drug events: a 10-year analysis.

June 8, 2005

Teaching medication reconciliation through simulation: a patient safety initiative for second year medical students.

July 23, 2008

The influence of organizational culture, climate and commitment on speaking up about medical errors.

December 18, 2019

Deploying and measuring a risk and patient safety program.

February 1, 2017

Information loss in emergency medical services handover of trauma patients.

September 23, 2009

Medication errors in HIV-infected hospitalized patients: a pharmacist's impact.

July 10, 2013

Locating errors through networked surveillance: a multimethod approach to peer assessment, hazard identification, and prioritization of patient safety efforts in cardiac surgery.

April 23, 2014

Surgeon fatigue: a prospective analysis of the incidence, risk, and intervals of predicted fatigue-related impairment in residents.

June 6, 2012

Electronic fetal heart rate monitoring: applying principles of patient safety.

May 16, 2012

Surveillance of medical device-related hazards and adverse events in hospitalized patients.

March 6, 2005

Introduction of a rapid response system at a United States Veterans Affairs hospital reduced cardiac arrests.

August 4, 2010

Promoting a culture of safety as a patient safety strategy: a systematic review.

March 13, 2013

Eight years of decreased methicillin-resistant Staphylococcus aureus health care–associated infections associated with a Veterans Affairs prevention initiative.

February 22, 2017

Improving measurement in clinical handover.

August 19, 2009

Creating high reliability in health care organizations.

December 20, 2006

Specimen labeling errors: a Q-probes analysis of 147 clinical laboratories.

November 12, 2008

Results of the Medications At Transitions and Clinical Handoffs (MATCH) study: an analysis of medication reconciliation errors and risk factors at hospital admission.

March 17, 2010

Outcomes in two Massachusetts hospital systems give reason for optimism about communication-and-resolution programs.

October 11, 2017

Development and evaluation of a 3-day patient safety curriculum to advance knowledge, self-efficacy and system thinking among medical students.

April 18, 2012

Using incident reporting to improve patient safety: a conceptual model.

March 28, 2007

Communicating with patients about diagnostic errors in breast cancer care: providers' attitudes, experiences, and advice

January 22, 2020

The relationship of the emotional climate of work and threat to patient outcome in a high-volume thoracic surgery operating room team.

March 16, 2011

Not overstepping professional boundaries: the challenging role of nurses in simulated error disclosures.

September 21, 2011

It's like sending a message in a bottle: a qualitative study of the consequences of one-way communication technologies in hospitals.

October 13, 2021

Resolving malpractice claims after tort reform: experience in a self-insured Texas public academic health system.

December 7, 2016

Accuracy of send-out test ordering: a College of American Pathologists Q-Probes study of ordering accuracy in 97 clinical laboratories.

March 12, 2008

High-reliability organisation principles implemented in dentistry.

July 27, 2022

Incident learning in radiation oncology: a review.

August 15, 2018

Operating room briefings: working on the same page.

June 14, 2006

Medication errors in paediatric care: a systematic review of epidemiology and an evaluation of evidence supporting reduction strategy recommendations.

April 18, 2007

Integrating the intensive care unit safety reporting system with existing incident reporting systems.

October 5, 2005

A learning health system agenda for organizational approaches to enhancing occupational well-being among clinicians.

May 25, 2022

Sleep deprivation, physician performance, and patient safety.

November 25, 2009

Sleep deprivation, elective surgical procedures, and informed consent.

January 12, 2011

An examination of technical efficiency, quality, and patient safety in acute care nursing units.

January 20, 2010

Intensive care unit safety incidents for medical versus surgical patients: a prospective multicenter study.

October 3, 2007

A system factors analysis of "line, tube, and drain" incidents in the intensive care unit.

August 24, 2005

Using radiofrequency technology to prevent retained sponges and improve patient outcomes.

October 28, 2020

Accountability for medical error: moving beyond blame to advocacy.

August 17, 2011

The role of language barriers on efficacy of rapid response teams.

March 1, 2023

Disclosing medical errors: prioritising the needs of patients and families.

July 5, 2023

Impact of duty hour limits on resident training in otolaryngology.

June 15, 2005

Anaesthetic adverse incident reports: an Australian study of 1,231 outcomes.

July 13, 2005

Medical-surgical nurse leaders' experiences with safety culture: an inductive qualitative descriptive study.

November 9, 2022

Measuring adverse events in hospitalized patients: an administrative method for measuring harm.

September 7, 2016

Does simulator-based clinical performance correlate with actual hospital behavior? The effect of extended work hours on patient care provided by medical interns.

November 3, 2010

(How) do we learn from errors? A prospective study of the link between the ward's learning practices and medication administration errors.

August 21, 2013

"To err is human" but disclosure must be taught: a simulation-based assessment study.

February 28, 2018

Executive/senior leader checklist to improve culture and reduce central line–associated bloodstream infections.

November 3, 2010

A multidisciplinary approach to reduce central line-associated bloodstream infections.

February 6, 2013

Case study: preventing surgical complications at Baystate Medical Center.

November 21, 2007

Creating an improvement culture for enhanced patient safety: service improvement learning in pre-registration education.

November 3, 2010

How medical error shapes physicians' perceptions of learning: an exploratory study.

August 21, 2019

Voluntarily reported emergency department errors.

November 30, 2005

Addressing bias in acute postoperative pain management.

October 11, 2023

Identification errors involving clinical laboratories: a College of American Pathologists Q-Probes study of patient and specimen identification errors at 120 institutions.

August 16, 2006

Improving surgical complications and patient safety at the nation's largest military hospital: an analysis of National Surgical Quality Improvement Program data.

March 29, 2017

Toward improving patient safety through voluntary peer-to-peer assessment.

January 25, 2012

Inter-professional clinical handover in post-anaesthetic care units: tools to improve quality and safety.

October 5, 2016

How radiation oncologists would disclose errors: results of a survey of radiation oncologists and trainees.

June 13, 2012

How patients can improve the accuracy of their medical records.

November 5, 2014

Making care better in the pediatric intensive care unit.

January 30, 2019

More than 1 million potential second victims: how many could nursing education prevent?

June 27, 2018

Making an infusion error: the second victims of infusion therapy-related medication errors.

May 30, 2018

Medication errors, routines, and differences between perioperative and non-perioperative nurses.

September 12, 2012

How to use online clinician rating systems.

October 14, 2015

A new infusion syringe label system designed to reduce task complexity during drug preparation.

June 27, 2007

Related Resources

Scaling up a diagnostic pause at the ICU-to-ward transition: an exploration of barriers and facilitators to implementation of the ICU-PAUSE handoff tool.

September 27, 2023

The delivery of safe and effective test result communication, management and follow-up.

September 27, 2023

Clinical pathway adherence and missed diagnostic opportunities among children with musculoskeletal infections.

September 6, 2023

Patient Safety Innovations

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

July 31, 2023

Developing electronic clinical quality measures to assess the cancer diagnostic process.

June 21, 2023

Patient Safety Innovations

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

May 31, 2023

Danger in discharge summaries: abbreviations create confusion for both author and recipient.

May 31, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

Patient Safety Innovations

Journal Article

Study

Catching those who fall through the cracks: integrating a follow-up process for emergency department patients with incidental radiologic findings.

November 16, 2022

The impact of an electronic alert to reduce the risk of co-prescription of low molecular weight heparins and direct oral anticoagulants.

July 6, 2022

It's like sending a message in a bottle: a qualitative study of the consequences of one-way communication technologies in hospitals.

October 13, 2021

Association between limiting the number of open records in a tele-critical care setting and retract-reorder errors.

July 21, 2021

The perfect storm: exam of a medical error and factors contributing to its possible escalation.

June 23, 2021

Reducing surgical specimen errors through multidisciplinary quality improvement.

June 16, 2021

Advanced medication reconciliation: a systematic review of the impact on medication errors and adverse drug events associated with transitions of care.

June 16, 2021

What are the implications for patient safety and experience of a major healthcare IT breakdown? A qualitative study.

May 26, 2021

How effective are electronic medication systems in reducing medication error rates and associated harm among hospital inpatients? A systematic review and meta-analysis.

December 2, 2020

Association of electronic health record use above meaningful use thresholds with hospital quality and safety outcomes.

October 21, 2020

Impact of interoperability of smart infusion pumps and an electronic medical record in critical care.

September 23, 2020

Contributing factors for pediatric ambulatory diagnostic process errors: Project RedDE.

July 15, 2020

WebM&M Cases

Direct Oral Anticoagulants are High-Risk Medications with Potentially Complex Dosing

June 24, 2020

Patient Safety Innovations

Verification Screen That Includes Prominent Patient Photograph Significantly Reduces Errors Caused by Orders Placed in Wrong Chart

June 12, 2020

Evaluating the impact of auto-calculation settings on opioid prescribing at an academic medical center.

May 8, 2019

Performing an inadvertent procedure.

January 30, 2019

Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors.

October 24, 2018

Frequency, comprehension and attitudes of physicians towards abbreviations in the medical record.

August 15, 2018

Interventions to improve follow-up of laboratory test results pending at discharge: a systematic review.

March 14, 2018

Electronic triggers to identify delays in follow-up of mammography: harnessing the power of big data in health care.

November 29, 2017

WebM&M Cases

Specimen Almost Lost

November 1, 2017

Orders on file but no labs drawn: investigation of machine and human errors caused by an interface idiosyncrasy.

March 22, 2017

See More About The Topic

Hospitals

Information Professionals

Hospital Medicine

Missed or Critical Lab Results

Epidemiology of Errors and Adverse Events

Pending studies at hospital discharge: a pre-post analysis of an electronic medical record tool to improve communication at hospital discharge.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Catching those who fall through the cracks: integrating a follow-up process for emergency department patients with incidental radiologic findings.

Verification Screen That Includes Prominent Patient Photograph Significantly Reduces Errors Caused by Orders Placed in Wrong Chart

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Pending studies at hospital discharge: a pre-post analysis of an electronic medical record tool to improve communication at hospital discharge.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Remote Response Team and Customized Alert Settings Help Improve Management of Sepsis

Catching those who fall through the cracks: integrating a follow-up process for emergency department patients with incidental radiologic findings.

Verification Screen That Includes Prominent Patient Photograph Significantly Reduces Errors Caused by Orders Placed in Wrong Chart

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site