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- Missed or Critical Lab Results
Journal Article > Study
Adequacy of hospital discharge summaries in documenting tests with pending results and outpatient follow-up providers.
Were MC, Li X, Kesterson J, et al. J Gen Intern Med. 2009;24:1002-1006.
Adverse events after hospital discharge are a continued threat to patient safety and a significant source of communication failures, particularly for tests that are pending at discharge. This study reviewed nearly 700 discharge summaries from two academic centers and found that only 16% of pending tests were mentioned and that only 13% of discharge summaries listed all pending tests. Equally concerning was that follow-up providers' information was documented in only 67% of cases. Recognition of these problems has led to the development of discharge checklists and reengineering of the process. A past AHRQ WebM&M perspective and interview discussed issues around safe care transitions.
Tools/Toolkit > Toolkit
Burlington, MA: Massachusetts Coalition for the Prevention of Medical Errors; 2003.