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 Win-win strategies for climate and food security
02.10.2017 | International Institute for Applied Systems Analysis (IIASA)

nachricht The personality factor: How to foster the sharing of research data
06.09.2017 | ZBW – Leibniz-Informationszentrum Wirtschaft

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: Neutron star merger directly observed for the first time

University of Maryland researchers contribute to historic detection of gravitational waves and light created by event

On August 17, 2017, at 12:41:04 UTC, scientists made the first direct observation of a merger between two neutron stars--the dense, collapsed cores that remain...

Im Focus: Breaking: the first light from two neutron stars merging

Seven new papers describe the first-ever detection of light from a gravitational wave source. The event, caused by two neutron stars colliding and merging together, was dubbed GW170817 because it sent ripples through space-time that reached Earth on 2017 August 17. Around the world, hundreds of excited astronomers mobilized quickly and were able to observe the event using numerous telescopes, providing a wealth of new data.

Previous detections of gravitational waves have all involved the merger of two black holes, a feat that won the 2017 Nobel Prize in Physics earlier this month....

Im Focus: Smart sensors for efficient processes

Material defects in end products can quickly result in failures in many areas of industry, and have a massive impact on the safe use of their products. This is why, in the field of quality assurance, intelligent, nondestructive sensor systems play a key role. They allow testing components and parts in a rapid and cost-efficient manner without destroying the actual product or changing its surface. Experts from the Fraunhofer IZFP in Saarbrücken will be presenting two exhibits at the Blechexpo in Stuttgart from 7–10 November 2017 that allow fast, reliable, and automated characterization of materials and detection of defects (Hall 5, Booth 5306).

When quality testing uses time-consuming destructive test methods, it can result in enormous costs due to damaging or destroying the products. And given that...

Im Focus: Cold molecules on collision course

Using a new cooling technique MPQ scientists succeed at observing collisions in a dense beam of cold and slow dipolar molecules.

How do chemical reactions proceed at extremely low temperatures? The answer requires the investigation of molecular samples that are cold, dense, and slow at...

Im Focus: Shrinking the proton again!

Scientists from the Max Planck Institute of Quantum Optics, using high precision laser spectroscopy of atomic hydrogen, confirm the surprisingly small value of the proton radius determined from muonic hydrogen.

It was one of the breakthroughs of the year 2010: Laser spectroscopy of muonic hydrogen resulted in a value for the proton charge radius that was significantly...

All Focus news of the innovation-report >>>

Anzeige

Anzeige

Event News

ASEAN Member States discuss the future role of renewable energy

17.10.2017 | Event News

World Health Summit 2017: International experts set the course for the future of Global Health

10.10.2017 | Event News

Climate Engineering Conference 2017 Opens in Berlin

10.10.2017 | Event News

 
Latest News

Terahertz spectroscopy goes nano

20.10.2017 | Information Technology

Strange but true: Turning a material upside down can sometimes make it softer

20.10.2017 | Materials Sciences

NRL clarifies valley polarization for electronic and optoelectronic technologies

20.10.2017 | Interdisciplinary Research

VideoLinks
B2B-VideoLinks
More VideoLinks >>>