New grant for patient safety research to prevent 'fumbled handoffs' leading to medical errors

When a football player drops the ball or fumbles a handoff, his team might lose yardage or return to the line of scrimmage to re-do the play. In healthcare, dropping the ball means a patient might not get necessary follow-up care or worse.

Martin Chieng Were, M.D., M.S., a Regenstrief Institute investigator and assistant professor of medicine at the Indiana University School of Medicine, has received a $420,000 award from the Harold Amos Medical Faculty Development Program of the Robert Wood Johnson Foundation-. The grant supports Were's patient safety research which focuses on using health information technology to improve post-hospital management of patients whose medical test results are still pending when a patient is discharged from the hospital.

Poor communication and management of such patients can lead to serious medical errors in post-hospitalization medical treatment. In a study published in the September 2009 issue of the Journal of General Internal Medicine, Dr. Were and colleagues reported that hospital discharge summaries are grossly inadequate at documenting both tests with pending results and information about which physicians should receive the post-discharge test results.

Although all the patients in the study 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.

"We found that a huge number- 72 percent- of test results requiring treatment change were not mentioned in discharge summaries. So an outpatient provider very likely would not have known that the results of these tests needed to be followed up. These 'fumbled handoffs' often lead to medical errors," said Dr. Were, who is an internist.

With the new award, Dr. Were plans to use health information technology to improve identification and communication of the tests ordered in the hospital that have pending results at the time of discharge. He will also work on systems to better identify the responsible follow-up healthcare providers for patients being discharged from the hospital, and to deliver test results that become available after discharge.

"As a hospital-based general internist, I care for patients with a host of problems for which I often perform tests that can take days or even weeks to come back from the lab. My patients usually don't need to stay in the hospital just waiting for these results, but there is no reliable system that allows me to be certain that those doctors who will be caring for my patient after discharge will track those test results and, if necessary, adjust the patient's treatment accordingly," said William Tierney, M.D., president and CEO of the Regenstrief Institute and associate dean for health-care effectiveness research at the IU School of Medicine. He also serves as chief of medicine at Wishard Health Services.