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1 March 2005 | Volume 142 Issue 5 | Pages 352-358
Missed follow-up of abnormal test results and resultant delays in diagnosis is a safety issue that is gaining increasing attention. Despite increases in the numbers and types of available diagnostic tests, current systems in health care do not reliably ensure that test results are received and acted upon by ordering physicians. This article examines the case of a patient whose diagnosis of tuberculosis was substantially delayed because of systems problems, including poor continuity (with multiple-provider involvement), lack of communication of test results and other clinical information, and several handoffs. Strategies to ensure adequate communication of critical information and follow-up of test results are discussed, such as explicit criteria for communication of abnormal results, test-tracking systems for ordering providers, and use of information technologies.
Author and Article Information
From Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts.
Acknowledgment: The author thanks Dr. Eric Poon, Erin Graydon-Baker, Saila Basavaraju, and Zahra Ladak for their contributions to this manuscript.
Grant Support: Funding for the Quality Grand Rounds series is supported by the California HealthCare Foundation as part of its Quality Initiative. The authors are supported by general institutional funds.
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Tejal Gandhi, MD, MPH, Brigham and Women's Hospital, 1620 Tremont Street, 3rd Floor, Boston, MA 02120; e-mail, tgandhi{at}partners.org. IMPROVING PATIENT CARE
QUALITY GRAND ROUNDS
Series Editors: Robert M. Wachter, MD; Kaveh G. Shojania, MD; Sanjay Saint, MD, MPH; Amy J. Markowitz, JD; and Mark Smith, MD, MBA
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.
Funding for the Quality Grand Rounds series is supported by the California Health Care Foundation as part of its Quality Initiative. The authors are supported by general institutional funds.
Fumbled Handoffs: One Dropped Ball after Another
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