Forum for Science, Industry and Business

Sponsored by:     3M 
Search our Site:

 

Fumbled handoffs can lead to medical errors

11.08.2009
Study finds not communicating results of tests after hospital discharge is common

Poor communication of the outcomes of medical tests whose results are pending at the time of a patient's hospital discharge is common and can lead to serious medical errors in post-hospitalization medical treatment.

A new study by researchers from the Regenstrief Institute and the Indiana University School of Medicine has found that hospital discharge summaries are grossly inadequate at documenting both tests with pending results and information about which doctors should receive the post-discharge test results. The findings appear in the September 2009 issue of the Journal of General Internal Medicine.

During a hospital stay tests are ordered by emergency department physicians, generalists, specialists, hospitalists and other medical staff. Test results such as those indicating positive blood culture, uncontrolled thyroid or declining kidney function can require post-discharge treatment but results of some tests may not be ready for weeks after the patient leaves the hospital. Most patients are unaware that test results are pending.

The new JGIM study identified 668 hospital discharges with pending test results. The researchers analyzed the discharge summaries and found them deficient.

Although all the patients had pending test results - only 16 percent of the 2,927 tests with pending results were mentioned in the discharge summaries

Only 67 percent of discharge summaries indicated which primary care outpatient doctor was responsible for following up with the patient after discharge.

Since the researchers looked retrospectively at the discharge summaries, they were able to see if test results reported after discharge called for a change in the patient treatment plan or management.

"We found that a huge number -- 72 percent -- of test results requiring treatment change were not mentioned in discharge summaries. So an outpatient provider likely would not even have known that the results of these tests needed to be followed up. In the patient safety arena, this is what you call a 'fumbled handoff' - and it leads to medical errors." said Martin Were, M.D., MS., first author of the study. Dr. Were is a Regenstrief Institute investigator and an assistant professor of medicine at the IU School of Medicine.

While it is easy to blame busy health-care providers for poor quality of discharge summaries, the problem largely reflects a failure in the system, according to Dr. Were. Similarly, in its seminal report 'To Err is Human', the Institute of Medicine advocates for changes in current systems to improve patient safety. "Our study highlights the need to improve how information is communicated to the outpatient follow-up providers," said Dr. Were, who is also an internist.

In addition to Dr. Were, authors of "Adequacy of Hospital Discharge Summaries in Documenting Tests with Pending Results and Outpatient Follow-up Providers" are Xiaochun Li, Ph.D. and Marc B. Rosenman, M.D. of the IU School of Medicine and Regenstrief Institute; Joe Kesterson, M.A. of the Regenstrief Institute and Jason Cadwallader, M.D., Chite Asirwa, M.D., and Babar Khan, M.D. of the IU School of Medicine.

This study was supported by grants from the National Library of Medicine and the National Center for Research Resources.

Cindy Fox Aisen | EurekAlert!
Further information:
http://www.iupui.edu

More articles from Studies and Analyses:

nachricht Smart Data Transformation – Surfing the Big Wave
02.12.2016 | Fraunhofer-Institut für Angewandte Informationstechnik FIT

nachricht Climate change could outpace EPA Lake Champlain protections
18.11.2016 | University of Vermont

All articles from Studies and Analyses >>>

The most recent press releases about innovation >>>

Die letzten 5 Focus-News des innovations-reports im Überblick:

Im Focus: Significantly more productivity in USP lasers

In recent years, lasers with ultrashort pulses (USP) down to the femtosecond range have become established on an industrial scale. They could advance some applications with the much-lauded “cold ablation” – if that meant they would then achieve more throughput. A new generation of process engineering that will address this issue in particular will be discussed at the “4th UKP Workshop – Ultrafast Laser Technology” in April 2017.

Even back in the 1990s, scientists were comparing materials processing with nanosecond, picosecond and femtosesecond pulses. The result was surprising:...

Im Focus: Shape matters when light meets atom

Mapping the interaction of a single atom with a single photon may inform design of quantum devices

Have you ever wondered how you see the world? Vision is about photons of light, which are packets of energy, interacting with the atoms or molecules in what...

Im Focus: Novel silicon etching technique crafts 3-D gradient refractive index micro-optics

A multi-institutional research collaboration has created a novel approach for fabricating three-dimensional micro-optics through the shape-defined formation of porous silicon (PSi), with broad impacts in integrated optoelectronics, imaging, and photovoltaics.

Working with colleagues at Stanford and The Dow Chemical Company, researchers at the University of Illinois at Urbana-Champaign fabricated 3-D birefringent...

Im Focus: Quantum Particles Form Droplets

In experiments with magnetic atoms conducted at extremely low temperatures, scientists have demonstrated a unique phase of matter: The atoms form a new type of quantum liquid or quantum droplet state. These so called quantum droplets may preserve their form in absence of external confinement because of quantum effects. The joint team of experimental physicists from Innsbruck and theoretical physicists from Hannover report on their findings in the journal Physical Review X.

“Our Quantum droplets are in the gas phase but they still drop like a rock,” explains experimental physicist Francesca Ferlaino when talking about the...

Im Focus: MADMAX: Max Planck Institute for Physics takes up axion research

The Max Planck Institute for Physics (MPP) is opening up a new research field. A workshop from November 21 - 22, 2016 will mark the start of activities for an innovative axion experiment. Axions are still only purely hypothetical particles. Their detection could solve two fundamental problems in particle physics: What dark matter consists of and why it has not yet been possible to directly observe a CP violation for the strong interaction.

The “MADMAX” project is the MPP’s commitment to axion research. Axions are so far only a theoretical prediction and are difficult to detect: on the one hand,...

All Focus news of the innovation-report >>>

Anzeige

Anzeige

Event News

ICTM Conference 2017: Production technology for turbomachine manufacturing of the future

16.11.2016 | Event News

Innovation Day Laser Technology – Laser Additive Manufacturing

01.11.2016 | Event News

#IC2S2: When Social Science meets Computer Science - GESIS will host the IC2S2 conference 2017

14.10.2016 | Event News

 
Latest News

Simple processing technique could cut cost of organic PV and wearable electronics

06.12.2016 | Materials Sciences

3-D printed kidney phantoms aid nuclear medicine dosing calibration

06.12.2016 | Medical Engineering

Robot on demand: Mobile machining of aircraft components with high precision

06.12.2016 | Power and Electrical Engineering

VideoLinks
B2B-VideoLinks
More VideoLinks >>>