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

Context Poor communication between inpatient and outpatient providers precedes many preventable adverse events that occur shortly after discharge. Contribution Forty-one percent of 2644 patients on the hospitalist services of 2 academic hospitals had pending laboratory or radiology results at discharge. Physician-reviewers deemed approximately 9% of these results potentially actionable. Physician surveys done 14 days after results were first available showed that physicians were unaware of many results and thought that about 13% of them required urgent action. Cautions Findings may not apply to nonacademic or nonhospitalist settings. Implications We need good integrated systems to assure follow-up of tests that are pending at discharge. The Editors Good communication between inpatient and outpatient physicians at the transition from hospital to home is critical to patient safety. However, the amount and complexity of information that must be relayed at hospital discharge are often overwhelming. Unfortunately, when communication breaks down, patients are at risk: More than half of all preventable adverse events occurring soon after hospital discharge have been related to poor communication among providers (1). Recently, the challenges to high-quality transitions of care have been increasingly recognized (2), and several factors may be contributing to communication failures at discharge. Although the introduction of hospitalist programs across the United States has produced positive results (3-5), the discontinuity of care inherent in the hospitalist model increases the likelihood of communication failures and makes thorough communication at discharge essential (6). Discontinuity is also an issue in teaching hospitals, where physicians-in-training may be responsible for some or all of the communication at discharge and, under new work-hour restrictions, may frequently change services or work in shifts. Whatever the cause, discontinuity of care at the inpatient-to-outpatient transition has been shown to be associated with medical errors (7). Among these errors is a failure to follow up on the results of laboratory tests and radiologic studies that return after discharge. Although timely follow-up on test results has received attention from the Agency for Healthcare Research and Quality (8) and failure to follow up on results has been recognized by a large malpractice insurer (9) as accounting for one quarter of diagnosis-related malpractice cases, few studies have addressed follow-up on test results pending at hospital discharge. Moore and colleagues (7) studied test follow-up errors, which were defined as having a test result noted as pending at discharge in the inpatient medical record but not acknowledged in the outpatient chart. Using retrospective chart review, they found this type of error in the records of 8% of all discharged patients and 41% of all patients discharged with pending test results, but their study design did not allow them to determine 1) whether clinicians were aware of the results and did not document them or 2) the clinical consequences of these errors. To our knowledge, no other studies have prospectively examined the prevalence and characteristics of test results that return after discharge or physician awareness of them. We hypothesized that test results pending at discharge are frequently overlooked in the handoff from the inpatient physician to the outpatient physician and that some of these results might have important clinical consequences for patients. Accordingly, we sought to prospectively determine the prevalence and characteristics of these potentially actionable results, to determine how often physicians are unaware of these results, and to evaluate the satisfaction of inpatient physicians with current systems for following up on results returning after discharge. Methods 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. Hospital A has 3 hospitalist inpatient teams that each consist of 1 hospitalist attending physician, 1 internal medicine resident, and 2 interns. At hospital A, the hospitalist attending physician is usually responsible for all communication to outpatient physicians at discharge, as well as for follow-up on all pending test results that return after discharge. Hospital B has 2 types of hospitalist services. One is nonhousestaff and is staffed only by hospitalist and nonhospitalist attending physicians; the nonhospitalist attending physicians care for their own patients on this service, but for the purposes of the study, we categorized them as inpatient physicians. The other hospitalist service at hospital B is a teaching service of 4 teams, each with 1 hospitalist attending physician, 1 junior resident, and 3 interns. On these teams at hospital B, the junior resident is responsible for communication at discharge and follow-up on all pending test results. During the study, 16 hospitalists were responsible for patient discharges at hospital A, 15 hospitalist and 93 nonhospitalist attending physicians were responsible for discharges on the nonhousestaff service at hospital B, and 54 junior residents were responsible for discharges on the teaching service at hospital B. Patient Selection and Identification of Results Returning after Discharge Using the hospital computer systems, we prospectively identified 2644 consecutive patients discharged from February to June 2004. Shortly after each patient's discharge, a research assistant entered into a database the patient's identifying information, discharge diagnosis, and times and dates of hospital admission and discharge. He or she then tracked each patient's pending test results by entering the patient on a watch list using a feature in a results-management system called Results Manager. Results Manager is a computer application that is fully integrated into the electronic medical record and is able to cull pending and final test results from the clinical data repository and to prioritize them on the basis of type of result and degree of abnormality. It was originally developed to track test results in the outpatient setting, and it has been evaluated and tested extensively in that setting but has not been used for inpatients (10). Data Collection We tracked test results with Results Manager for 14 days after patient discharge. A research assistant screened all laboratory and radiologic test results returning after discharge and excluded the results of tests done after discharge. Normal, near-normal, and stable results were excluded by using a predefined algorithm (Figure 1). If a result was abnormal, it was sent to 1 of 4 physician-reviewers who, using the electronic medical record, reviewed the discharge diagnosis; any related test results; and the discharge order, note, or summary (when available) to determine whether the result was potentially actionable. Any result mentioned in the discharge summary was excluded (these were most often final radiologic test results that did not differ from the preliminary results available to the inpatient team). Figure 1. Identifying results for physician review At both hospitals, the discharge order (including discharge diagnoses, medications, and follow-up appointments) was entered into the electronic medical record on the day of discharge and therefore was always available at the time of physician review. Of the 671 results that we reviewed, 525 (78%) were for patients who also had a dictated or typed discharge summary available at the time of review. When discharge summaries are completed after hospital discharge, inpatient physicians have access to the electronic medical record, including any test results that were not available on the day of discharge. The physician-reviewers are board-certified internists; 2 are hospitalists, and 2 are primary care physicians. If a physician-reviewer was involved in the care of a patient who had a result that required review, that result was sent to one of the other 3 reviewers. After reviewing the discharge order, the discharge summary, and related test results, the physician-reviewer used clinical judgment to determine whether the result required clinical action on the basis of the available information. A result was considered potentially actionable if it could change the management of the patient by requiring a new treatment or diagnostic test (or repeated testing), modification or discontinuation of a treatment or diagnostic testing, scheduling of an earlier follow-up appointment, or referral of the patient to another physician or specialist. The reviewer rated the result as definitely actionable, probably actionable, probably not actionable, or definitely not actionable. The reviewer also rated the urgency of the required action according to how soon it should occur: within 1 hour, 8 hours, 24 hours, 72 hours, 1 week, or 1 month. Surveys If the physician-reviewer defined a result as definitely actionable or probably actionable, either the inpatient physician or the primary care physician was surveyed by e-mail to determine whether he or she was aware of the result. At hospital A, the attending hospitalist was the inpatient physician surveyed; on the teaching service at hospital B, the junior resident was surveyed. On the nonhousestaff service at hospital B, the hospitalist or nonhospitalist attending physician was surveyed as the inpatient physician. The