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PSNet: Patient Safety Network
Journal Article
Review

The safety implications of missed test results for hospitalised patients: a systematic review.

Callen J, Georgiou A, Li J, et al. BMJ quality & safety. 2011;20:194-9.

Adverse events after hospital discharge are a growing driver for safety interventions, including a focus on readmissions, adverse drug events, and hospital-acquired infections. Another safety area ripe for intervention is managing test results after hospital discharge. This systematic review analyzed 12 studies and found wide variation in rates of test follow-up and related management systems. Critical test results and results for patients moving across health care settings were highlighted as particularly concerning areas that could be addressed with better clinical information systems. A past AHRQ WebM&M commentary discussed a case where a patient was incorrectly treated based on failure to follow up a urine culture after hospital discharge.