Adverse events after hospital discharge are a continued threat to patient safety and a significant source of communication failures, particularly for tests that are pending at discharge. This study reviewed nearly 700 discharge summaries from two academic centers and found that only 16% of pending tests were mentioned and that only 13% of discharge summaries listed all pending tests. Equally concerning was that follow-up providers' information was documented in only 67% of cases. Recognition of these problems has led to the development of discharge checklists and reengineering of the process. A past AHRQ WebM&M perspective and interview discussed issues around safe care transitions.