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Patient safety concerns arising from test results that return after hospital discharge. Classic icon
Roy CL, Poon EG, Karson AS, et al. Ann Intern Med. 2005;143:121-128.

This study followed more than 2600 discharged patients from two hospitalist services to capture the number and types of test results that required intervention. Investigators discovered that nearly 40% of patients enrolled had a pending lab or radiology test with 9% requiring action. Discussion also includes survey findings from inpatient providers, which demonstrated poor awareness of pending studies and general dissatisfaction with current systems to manage test follow-up. The authors conclude that future efforts to reduce these preventable errors in discharge follow-up require improved systems for retrieving tests after discharge and better communication between inpatient and outpatient providers.

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