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Patient Safety Concerns Arising from Test Results That Return after
Hospital Discharge
Christopher L. Roy, MD; Eric G. Poon, MD, MPH; Andrew S. Karson, MD, MPH; Zahra Ladak-Merchant, BDS, MPH; Robin E. Johnson, BA;
Saverio M. Maviglia, MD, MSc; and Tejal K. Gandhi, MD, MPH
Background: Failure to relay information about test results
pending when patients are discharged from the hospital may pose
an important patient-safety problem. Few data are available on
the epidemiology of test results pending at discharge or on phy-
sician awareness of these results.
Objective: To determine the prevalence, characteristics, and phy-
sician awareness of potentially actionable laboratory and radio-
logic test results returning after hospital discharge.
Design: Cross-sectional study.
Setting: Two tertiary care academic hospitals.
Patients: 2644 consecutive patients discharged from hospitalist
services from February to June 2004.
Measurements: The main outcomes were the prevalence and
characteristics of potentially actionable test results returning after
hospital discharge, awareness of these results by inpatient and
primary care physicians, and satisfaction of inpatient physicians
with current systems for follow-up on test results. The authors
prospectively collected data on test results pending at the time of
discharge and, as results returned after discharge, surveyed hos-
pitalists, junior residents, and primary care physicians about those
results that were potentially actionable according to a physician-
reviewer.
Results: A total of 1095 patients (41%) had 2033 test results
return after discharge. Of these results, 191 (9.4% [95% CI, 8.0%
to 11.0%]) were potentially actionable. Surveys were sent regard-
ing 155 results, and 105 responses were returned. Of the 105
results in the surveys with responses, physicians had been un-
aware of 65 (61.6% [CI, 51.3% to 70.9%]); of these 65, they
agreed with physician-reviewers that 24 (37.1% [CI, 25.7% to
50.2%]) were actionable and 8 (12.6% [CI, 6.4% to 23.3%])
required urgent action. Inpatient physicians were dissatisfied with
their systems for following up on test results returning after dis-
charge.
Limitations: The authors were unable to determine whether
physicians’ lack of awareness of test results returning after dis-
charge was associated with adverse outcomes.
Conclusions: Many patients are discharged from hospitals with
test results still pending, and physicians are often unaware of
potentially actionable test results returning after discharge. Further
work is needed to design better follow-up systems for test results
returning after hospital discharge.
Ann Intern Med. 2005;143:121-128. www.annals.org
For author affiliations, see end of text.
G
ood communication between inpatient and outpa-
tient 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 fac-
tors may be contributing to communication failures at dis-
charge. 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
See also:
Print
Editors’ Notes .............................122
Web-Only
Conversion of figures and tables into slides
Improving Patient Care
© 2005 American College of Physicians 121
Improving Patient Care is a special section within Annals supported in part by the U.S. Department of Health and Human Services (HHS) Agency for Healthcare Research and Quality
(AHRQ). The opinions expressed in this article are those of the authors and do not represent the position or endorsement of AHRQ or HHS.
record but not acknowledged in the outpatient chart. Us-
ing 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 deter-
mine 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 ap-
proved 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 elec-
tronic 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 med-
icine resident, and 2 interns. At hospital A, the hospitalist
attending physician is usually responsible for all communi-
cation to outpatient physicians at discharge, as well as for
follow-up on all pending test results that return after dis-
charge. Hospital B has 2 types of hospitalist services. One
is nonhousestaff and is staffed only by hospitalist and non-
hospitalist attending physicians; the nonhospitalist attend-
ing 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 hospi-
tal 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 pend-
ing test results. During the study, 16 hospitalists were re-
sponsible for patient discharges at hospital A, 15 hospitalist
and 93 nonhospitalist attending physicians were responsi-
ble 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 Feb-
ruary to June 2004. Shortly after each patient’s discharge, a
research assistant entered into a database the patient’s iden-
tifying 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-man-
Figure 1. Identifying results for physician review
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 ser-
vices 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 ur-
gent 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
Improving Patient Care Patient Safety Concerns Arising from Test Results That Return after Hospital Discharge
122 19 July 2005 Annals of Internal Medicine Volume 143 • Number 2 www.annals.org
agement 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 re-
sults 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 dis-
charge and excluded the results of tests done after dis-
charge. Normal, near-normal, and stable results were ex-
cluded by using a predefined algorithm (Figure 1). If a
result was abnormal, it was sent to 1 of 4 physician-review-
ers who, using the electronic medical record, reviewed the
discharge diagnosis; any related test results; and the dis-
charge order, note, or summary (when available) to deter-
mine 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 in-
patient team).
At both hospitals, the discharge order (including dis-
charge diagnoses, medications, and follow-up appoint-
ments) 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 re-
quired clinical action on the basis of the available informa-
tion. 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 diagnos-
tic 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 “def-
initely 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 in-
patient physician surveyed; on the teaching service at hos-
pital B, the junior resident was surveyed. On the nonhouse-
staff service at hospital B, the hospitalist or nonhospitalist
attending physician was surveyed as the inpatient physi-
cian. The survey e-mail included the actual result and the
patient’s name and discharge diagnosis. Inpatient physi-
cians were surveyed 72 hours after a result became available
in the electronic medical record, whereas primary care phy-
sicians were surveyed 14 days after a result was available,
with the reasoning that most patients would have a post-
discharge follow-up appointment within 14 days. Physi-
cians who did not respond to the first survey e-mail re-
ceived a second survey e-mail 3 days later.
Because the inpatient physician could notify the pri-
mary care physician about a result after receiving the survey
e-mail, we surveyed only the inpatient physician or the
primary care physician about a given result. If the patient’s
primary care physician could not be identified or was not
accessible by e-mail, or if the patient was not discharged to
home, we surveyed the inpatient physician instead. If the
inpatient physician had clearly documented in the dis-
charge summary that the primary care physician had been
informed of the pending test result, we surveyed the pri-
mary care physician. Thirty-four percent of surveys were
specifically assigned to either the inpatient physician or the
primary care physician; the rest were randomly assigned.
To preserve patient safety, we sent the survey e-mail to the
inpatient physician without delay in all cases in which ab-
normal test results were considered urgent (requiring ac-
tion within 72 hours). If no response was obtained or if the
result was critical, the inpatient physician and primary care
physician were paged immediately.
The same survey was used for both inpatient physi-
cians and primary care physicians. After being presented
with the patient’s name, discharge diagnosis, and test re-
sult, physicians were asked whether they had been aware of
the result before receiving the survey. If they answered
“yes,” they were asked how they had become aware of it,
whether they had known that the test had been ordered,
whether the result had changed the patient’s diagnostic or
therapeutic plan, how urgent the result was, and what ac-
tion or actions they had taken because of the result. If they
answered “no,” they were asked whether they had known
that the test had been ordered, whether the result would
change the patient’s diagnostic or therapeutic plan, how
urgent the result was, and what action or actions they
would take because of the result.
Improving Patient CarePatient Safety Concerns Arising from Test Results That Return after Hospital Discharge
www.annals.org 19 July 2005 Annals of Internal Medicine Volume 143 • Number 2 123
At the beginning of the study, we surveyed inpatient
physicians about their satisfaction with their current system
for following up on test results returning after discharge.
Responses were rated on a Likert scale. We asked inpatient
physicians how concerned they were about their ability to
follow up on test results returning after discharge, about
test results not being followed up on, about their knowl-
edge of what test results are pending at discharge, and
about their ability to communicate test results returning
after discharge to primary care physicians. We also asked
whether they believed that a computer system could help
track these results and whether they were comfortable us-
ing the hospital’s electronic medical record.
Outcomes
The primary outcomes of interest were the prevalence
and characteristics of potentially actionable results return-
ing after discharge, the awareness of these results on the
part of inpatient and primary care physicians, and the sat-
isfaction of inpatient physicians with their current system
of tracking these results.
Statistical Analysis
Some patients with results returning after discharge
were discharged by the same inpatient physician. To ac-
count for the clustering of test results within discharging
inpatient physicians, we used generalized estimating equa-
tions to calculate the prevalence of potentially actionable
results and 95% confidence intervals. We used a similar
approach to calculate rates of awareness of potentially ac-
tionable results among surveyed physicians. To ascertain
the relationship between various subgroups and awareness
rates, we built clustered multivariable regression models.
Clustered analyses were done by using PROC GENMOD
in SAS, version 8 (Cary, North Carolina). Surveys were
administered by using Perseus SurveySolutions 6.0.148
(Perseus Development Corp., Braintree, Massachusetts).
Role of the Funding Source
The funding source had no role in the design, analysis,
or interpretation of the study or in the decision to submit
the manuscript for publication.
RESULTS
Postdischarge Results
Of the 2644 patients discharged from the hospitalist
services during the study period, 1095 (41%) had a total of
2033 test results pending on the day of discharge, and 877
of these results (43%) were abnormal (Figure 2). Of these
877 abnormal results, we excluded 206 because they were
near-normal or stable compared with previous values. A
physician reviewed the remaining 671 results (33% of the
pending results), and 191 results (9.4% of the pending
results [95% CI, 8.0% to 11.0%]) from 177 patients were
considered potentially actionable on the basis of review of
the discharge orders and summary. For these 191 results,
we sent 155 surveys. In 31 cases, we could not identify the
primary care physician, and in 5 cases, multiple results for
the same patient were combined in 1 survey e-mail.
Response Rates
We sent 155 surveys (98 to inpatient physicians and
57 to primary care physicians) and received 105 responses;
72 were from inpatient physicians (31 responses came from
11 hospitalists, 6 responses came from 5 nonhospitalist
attending physicians, and 35 responses came from 18 jun-
ior residents), and 33 were from 28 primary care physi-
cians. The response rate was 73% for inpatient physicians
Figure 2. Identification of potentially actionable postdischarge
results
Table 1. Survey Responses of 34 Inpatient Physicians and 28
Primary Care Physicians about Their Awareness of Potentially
Actionable Postdischarge Results and Their Awareness of Tests
Having Been Ordered*
Type of Physician
Responding
Responses,
n
Physicians Who
Had Been
Unaware of Result
(95% CI), %
Physicians Who
Had Been
Unaware That Test
Had Been Ordered
(95% CI), %
Inpatient (n ⫽ 34) 72 70.0† (57.0–80.4) 24.6‡ (14.2–39.2)
Primary care (n ⫽ 28) 33 45.8† (30.4–62.1) 45.8‡ (29.5–63.0)
All (n ⫽ 62) 105 61.6 (51.5–70.9) 33.1 (23.4–44.4)
*Clustered univariate analyses.
† P ⫽ 0.02.
‡ P ⫽ 0.06.
Improving Patient Care Patient Safety Concerns Arising from Test Results That Return after Hospital Discharge
124 19 July 2005 Annals of Internal Medicine Volume 143 • Number 2 www.annals.org
and 58% for primary care physicians. The overall response
rate was 68%.
Physician Awareness of Results
Table 1 shows awareness by inpatient and primary
care physicians of 1) potentially actionable test results and
2) a test having been ordered. Of the 105 results for which
62 physicians returned surveys, physicians had been un-
aware of 65 (unawareness rate, 61.6% [CI, 51.5% to
70.9%]). Inpatient physicians were less likely than primary
care physicians to be aware of results (bivariate odds ratio,
0.36 [CI, 0.15 to 0.86]; P ⫽ 0.02). Surveyed physicians
had been unaware that a test had been ordered in the case
of 31 of 105 results (awareness rate, 33.0% [CI, 23.4% to
44.4%]).
When we examined awareness of results in various
subgroups, comparing hospital A with hospital B, house-
staff teams with nonhousestaff teams, and teams on which
the inpatient physician responsible for the discharge com-
munication was an attending physician with teams on
which the inpatient physician responsible for the discharge
communication was a resident, we found no significant
differences on either bivariate or multivariate analyses.
However, awareness that the test had been ordered was
significantly higher among surveyed physicians when the
inpatient physician responsible for discharge communica-
tion was a resident (bivariate odds ratio, 8.0 [CI, 1.9 to
33.4]; P ⫽ 0.004).
Of the 40 results of which surveyed physicians had
been aware before receiving the survey e-mail, they had
learned of 28 by reviewing the electronic medical record,
had been notified of 5 by housestaff or a medical student,
had been notified of 4 by another physician, and had been
notified of 3 by laboratory or radiology personnel.
Actionability, Urgency, and Nature of Results
Of the 105 potentially actionable results for which
surveys were returned, surveyed physicians “strongly
agreed” or “agreed” with the physician-reviewer that 35
results (33.3% [CI, 24.7% to 43.1%]) were actionable,
changing the diagnostic or therapeutic plan for the patient,
and that 15 results (14.2% [CI, 8.7% to 22.5%]) required
urgent action. Of the 65 potentially actionable results of
which physicians were not aware, surveyed physicians
“strongly agreed” or “agreed” that 24 results (37.1% [CI,
25.7% to 50.2%]) were actionable, changing the diagnos-
tic or therapeutic plan for the patient, and that 8 results
(12.6% [CI, 6.4% to 23.3%]) required urgent action. Ta-
ble 2 shows a sample of urgent actionable results of which
surveyed physicians were not aware. Of the 8 results that
Table 2. Examples of Actionable Results of Which Surveyed Physicians Had Been Unaware
Discharge Diagnosis Situation at Discharge Postdischarge Test Result
Actionable results requiring urgent action
Diabetic ketoacidosis, septic thrombophlebitis Patient discharged to rehabilitation
receiving vancomycin for septic
thrombophlebitis with
methicillin-resistant Staphylococcus
aureus
Blood culture grew Clostridium perfringens
during vancomycin treatment
Chest pain, rapid atrial fibrillation Patient treated for rapid atrial fibrillation Thyroid-stimulating hormone level was
⬍0.01
IU/mL (normal range, 0.40–
5.0
IU/mL), consistent with a new
diagnosis of hyperthyroidism
Pulmonary emboli Patient receiving levofloxacin for urinary
tract infection
Urine culture grew ⬎100 000 colonies of
Klebsiella pneumoniae resistant to
levofloxacin
Duodenal ulcer Patient discharged without antibiotic
therapy
Urine culture grew ⬎100 000 colonies of
Pseudomonas aeruginosa
Facial cellulitis, intravenous drug use Patient received nafcillin for facial
cellulitis and abscess
Wound culture grew methicillin-resistant
Staphylococcus aureus
Actionable results not requiring urgent action
Gastritis Patient admitted with epigastric pain
presumed to be due to gastritis and
discharged receiving proton-pump
inhibitors but not antibiotics
Result on serologic test for Helicobacter
pylori was positive
Low back pain, urinary incontinence,
elevated liver function test results, and
hypercalcemia
Patient admitted with low back pain
and urinary incontinence
Ferritin level (18
g/L) consistent with iron
deficiency
Angioedema due to lisinopril Patient intubated for angioedema and
discharged without antibiotic
treatment
Final chest radiograph was consistent with
possible early pneumonia
Alcohol withdrawal, seizures Patient admitted with seizures and
alcohol withdrawal
Computed tomographic scan of the chest,
obtained in the emergency department
to rule out pulmonary embolus, was
positive for lung nodules; follow-up was
recommended
Alcoholic hepatitis Patient had elevated aminotransferase
levels thought to be due to heavy
alcohol use
Hepatitis C viral load was 4 680 920
IU/mL
Improving Patient CarePatient Safety Concerns Arising from Test Results That Return after Hospital Discharge
www.annals.org 19 July 2005 Annals of Internal Medicine Volume 143 • Number 2 125
required urgent action, 6 were microbiological test results
(blood, urine, and wound cultures) that necessitated the
starting or changing of antibiotic therapy. One patient who
had been admitted to the hospital with new atrial fibrilla-
tion had an undetectable thyroid-stimulating hormone
level consistent with a new diagnosis of hyperthyroidism.
Actionable but nonurgent results included 3 incidental
findings of a pulmonary nodule or nodules or opacities on
chest radiography or computed tomography that required
follow-up, 5 positive serologic test results for Helicobacter
pylori in patients with gastrointestinal bleeding or dyspep-
sia, a very high hepatitis C viral load in a patient admitted
to the hospital with presumed alcoholic hepatitis, and a
finding of iron deficiency.
There were significantly more “definitely actionable”
than “probably actionable” ratings by physician-reviewers
among the 105 results for which surveys were returned
than among the 86 potentially actionable results for which
surveys were not returned or not sent (42% compared with
27%; P ⫽ 0.046).
Actions Taken
Surveyed physicians were asked what action or actions
they would take as a result of the survey e-mail; the data for
results of which physicians had been unaware are summa-
rized in Table 3. Physicians could choose more than 1
action. Twenty-one physicians said that they would notify
the patient’s primary care physician, 8 said that they would
refer the patient to his or her primary care physician or
another physician, 5 said that they would order further
testing or treatment, 5 said that they would inform the
patient of the result, 2 said that they would review the
medical record, and 1 said that he or she would notify the
patient’s extended care facility. None said that he or she
would refer the patient to the emergency department or
hospital, and 25 said that they would take no action.
Satisfaction among Inpatient Physicians
We assessed the satisfaction of inpatient physicians
with their current ability to follow up on results returning
after discharge. Of 44 inpatient physicians surveyed (in-
cluding hospitalists and junior residents), 34 responded
(77% response rate). Of these 34 responders, 74% were
concerned about their ability to follow up on test results,
85% were concerned about results not being followed up
on, 65% were concerned about what tests are pending at
discharge, and 54% were concerned about their ability to
communicate these results to primary care physicians. All
respondents agreed that computer systems could help track
these results, and 64% said that they were comfortable
using the hospital’s electronic medical record.
DISCUSSION
In this study of hospitalist services at 2 major tertiary
care centers, we found that almost half of discharged pa-
tients had pending laboratory and radiologic test results
and that 9% of these results were potentially clinically ac-
tionable. Surveyed physicians were unaware of almost two
thirds of these potentially actionable results; more than a
third of these would change the patient’s diagnostic or
therapeutic plan, and 12.6% required urgent action. The
most common results requiring urgent action were results
of microbiological tests necessitating initiation or change of
antibiotic treatment. Many nonurgent actionable results
were from radiologic studies (for example, incidental pul-
monary nodules) or serologic tests (for example, H. pylori
titers). Inpatient and primary care physicians often did not
know what tests had been ordered and had results pending
at discharge, perhaps reflecting the ordering of tests by
several team members and physicians-in-training. Finally,
most inpatient physicians were dissatisfied with their cur-
rent ability to follow up on results returning after dis-
charge, and they agreed that computer systems could make
this follow-up easier.
Among 2644 patients discharged over the 5-month
study period, we discovered only 15 results returning after
discharge that were considered urgent by clinicians (the
clinicians were unaware of 8 of these) and 35 results re-
turning after discharge that changed the patient’s diagnos-
tic or therapeutic plan (the clinicians were unaware of 24
of these). Despite these small numbers, the implications for
patient safety remain impressive: Almost half of all dis-
charged patients had pending test results, 6% of these pa-
tients had results considered potentially actionable by a
physician-reviewer, and physician awareness of these results
was low. Failure to follow up on certain results (for exam-
ple, the results of blood cultures) could have catastrophic
consequences, but even results that do not require urgent
action (such as discovery of a pulmonary nodule or iron
deficiency) could have important consequences if over-
looked. Given the high volume of results returning after
discharge and the potential for patient harm if even a few
Table 3. Actions That Would Be Taken by Surveyed Physicians
upon Learning of a Postdischarge Result
Action All
Physicians, n
Inpatient
Physicians, n
Primary
Care
Physicians,
n
Notify primary care
physician
21 20 1*
Order further testing
or treatment
51 4
Refer patient to
primary care
physician or other
physician
84 4
Inform patient 5 2 3
Inform extended care
facility
11 0
Review medical record 2 2 0
None 25 22 3
*The primary care physician who gave this response was not the patient’s actual
primary care physician but was seeing the patient during follow-up.
Improving Patient Care Patient Safety Concerns Arising from Test Results That Return after Hospital Discharge
126 19 July 2005 Annals of Internal Medicine Volume 143 • Number 2 www.annals.org
results are overlooked, a highly reliable system for ensuring
follow-up seems warranted. The limitations of our study
notwithstanding, if we extrapolate our findings, an error
rate of 0.9 per 100 patient discharges, or about 10
-2
(24
missed actionable results among 2644 patient discharges),
would fall far short of a target error rate of 10
-6
set in other
high-risk industries (11) and would translate into 270
missed actionable results in a hospital with 30 000 dis-
charges per year.
Our findings have special implications for teaching
hospitals. When responding to our survey e-mails, both
primary care and inpatient physicians were often unaware
that a test had been ordered. It is not surprising that a
primary care physician would not know of every test or-
dered during a hospitalization for which he or she is not
the attending physician of record, but the fact that an in-
patient physician is not aware of an ordered test suggests
that another team member (perhaps an intern or resident)
wrote the order without the inpatient physician’s knowl-
edge. Of note, on teams on which the discharging physi-
cian was a resident compared with teams on which the
discharging physician was not a resident, awareness that a
test was ordered was higher (although awareness of the test
result was not). In teaching hospitals where multiple team
members are involved in ordering tests, systems must be in
place to ensure that the persons responsible for test fol-
low-up are aware of all tests that have been ordered and
have results pending at discharge. In addition, as we found,
many tests ordered in the inpatient setting that still have
results pending at discharge are irrelevant to the patient’s
care. Therefore, while we should strive for fail-safe com-
munication, we should also be circumspect about ordering
tests in the inpatient setting.
Dissatisfaction with systems of follow-up on abnormal
test results has been documented in primary care (12, 13),
and we saw similar findings among inpatient physicians.
The discharge summary remains the standard means for
communicating information about pending test results,
but it may not be reliable; in some studies, discharge sum-
maries are available for only 12% to 33% of follow-up
visits (14 –16). Nonselective mailing to physicians of all
inpatient laboratory and radiologic test results risks losing
important abnormal results among normal ones and is an
ineffective way to communicate results requiring urgent
action. Electronic results-management systems are being
evaluated to solve the problem of timely and reliable test
follow-up in the outpatient setting (10), and such technol-
ogy may be useful to hospitalists in tracking results return-
ing after discharge. Such systems could highlight important
results and filter out normal results to avoid overwhelming
busy clinicians. Our survey shows that our inpatient phy-
sicians would be eager to adopt such systems, and a second
phase of this study will examine the effect of an electronic
results-management system on physician awareness of re-
sults returning after discharge.
Our study results should be interpreted in light of
several limitations. First, although the surveys were confi-
dential, they were not anonymous, and physicians may
have been reluctant to report lack of awareness of test re-
sults for reasons of liability. Thus, our response rate was
relatively low, especially among primary care physicians,
and our results may have been subject to responder bias; it
is not clear whether survey respondents would have been
more or less likely than nonrespondents to be aware of
results returning after discharge. However, we found that
surveys that received a response had a higher percentage of
results rated as “definitely actionable” by the physician-
reviewer, suggesting that surveyed physicians were more
likely to respond to results with more clinical importance.
Second, surveyed physicians agreed with our physician-re-
viewers that a potentially actionable result required clinical
action in only about one third of cases. From our data, we
are unable to determine the reason for this disagreement.
We suspect that the physician-reviewers used a broader
definition of “actionable,” including results that did not
require immediate attention but required action nonethe-
less, and were basing their assessments on the medical
record alone, whereas the surveyed physicians may have
used a narrower definition of “actionable” and had more
knowledge of the clinical context. Third, we did not for-
mally test agreement among physician-reviewers on action-
ability. Fourth, we could not determine whether unaware-
ness of a test result was associated with adverse outcomes
for patients or whether physicians would have eventually
learned of a given result themselves. However, we believe
that we allowed sufficient time for physicians to learn
about results (72 hours for inpatient physicians and 14
days for primary care physicians). Finally, our study was
done in 2 academic tertiary care centers with hospitalists,
housestaff, a shared electronic medical record, and com-
puterized provider order entry, and our findings may not
be generalizable to institutions without these characteris-
tics. In fact, few hospitals currently have a shared electronic
medical record that both outpatient and inpatient physi-
cians can access (17). Without such a system, awareness of
potentially actionable results returning after discharge
would probably be lower still.
We conclude that patients are frequently discharged
from hospitals with test results still pending, that physi-
cians are often unaware of potentially important test results
returning after discharge, and that some of these results
require urgent action. Future studies should focus on sys-
tems to ensure fail-safe communication of and follow-up
on test results returned after hospital discharge.
From Brigham and Women’s Hospital and Massachusetts General Hos-
pital, Boston, Massachusetts.
Acknowledgments: The authors thank Mr. Justin Golden and Mr.
Martin Spera.
Grant Support: By a grant from the Harvard Risk Management Foun-
dation, Cambridge, Massachusetts.
Improving Patient CarePatient Safety Concerns Arising from Test Results That Return after Hospital Discharge
www.annals.org 19 July 2005 Annals of Internal Medicine Volume 143 • Number 2 127
Potential Conflicts of Interest: None disclosed.
Requests for Single Reprints: Christopher L. Roy, MD, Brigham and
Women’s Hospital, 75 Francis Street, Boston, MA 02115; e-mail,
croy@partners.org.
Current author addresses are available at www.annals.org.
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Current Author Addresses: Drs. Roy and Maviglia: Brigham and
Women’s Hospital, 75 Francis Street, Boston, MA 02115.
Drs. Poon and Gandhi, Ms. Ladak-Merchant, and Ms. Johnson:
Brigham and Women’s Hospital, 1620 Tremont Street, Boston, MA
02120.
Dr. Karson: Massachusetts General Hospital, 55 Fruit Street, Boston,
MA 02114.
www.annals.org 19 July 2005 Annals of Internal Medicine Volume 143 • Number 2 W-31
