The DOI matches its Crossref record; 19 of the 19 references it cites were found in a registry or an index.
Fumbled Handoffs: One Dropped Ball after Another
Abstract
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.
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In the citing paper
“missed laboratory results or delayed recognition of results leads to a significant potential for outpatient diagnostic errors, adverse events and liability claims.”
From Notification of Abnormal Lab Test Results in an Electronic Medical Record: Do Any Safety Concerns Remain? (2010) · cites this paper as [11]
In the citing paper
“Communication breakdowns are an increasingly recognized preventable factor in medical mishaps, and emerging data suggest a high prevalence of communication breakdowns among physicians, patients, and important members of the health care team who assist with the diagnostic process.21,25–32”
From Reducing Diagnostic Errors through Effective Communication: Harnessing the Power of Information Technology (2008) · cites this paper as [21]
In the citing paper
“Communication breakdowns are an increasingly recognized preventable factor in medical mishaps, and emerging data suggest a high prevalence of communication breakdowns among physicians, patients, and important members of the health care team who assist with the diagnostic process.21,25–32”
From Reducing Diagnostic Errors through Effective Communication: Harnessing the Power of Information Technology (2008) · cites this paper as [21]
Citations
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“A recent study demonstrated lower error rates by medical interns working 12-hour instead of 30-hour shifts (18).”
BackgroundThe Working Hours Of Hospital Staff Nurses And Patient Safety
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“With respect to human factors, little is known about the detrimental effects of physician workload on quality and safety, although there have been several studies of the correlation between nurse staffing and errors (16, 17).”
BackgroundDoes Housestaff Discontinuity of Care Increase the Risk for Preventable Adverse Events?
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Research works printed but not linked: 1
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Cited by
Sorted by citations
Missed and delayed diagnoses in the ambulatory setting: a study of closed malpractice claims
Gandhi, T. K., Kachalia, A., Thomas, E. J., Puopolo, A. L., Yoon, C., Brennan, T. A., & Studdert, D. M. (2006) · Annals of Internal Medicine · doi:10.7326/0003-4819-145-7-200610030-00006 · Cited by 662
Self-citationThe Global Burden of Diagnostic Errors in Primary Care
Singh, H., Schiff, G. D., Graber, M. L., Onakpoya, I., & Thompson, M. J. (2017) · BMJ Quality & Safety · doi:10.1136/bmjqs-2016-005401 · Cited by 395
Residents’ and Attending Physicians’ Handoffs: A Systematic Review of the Literature
Riesenberg, L. A., Leitzsch, J., Massucci, J. L., Jaeger, J., Rosenfeld, J. C., Patow, C., Padmore, J. S., & Karpovich, K. P. (2009) · Academic Medicine · doi:10.1097/acm.0b013e3181bf51a6 · Cited by 345
Transfers of Patient Care Between House Staff on Internal Medicine Wards: A National Survey
Horwitz, L. I., Krumholz, H. M., Green, M. L., & Huot, S. J. (2006) · Archives of Internal Medicine · doi:10.1001/archinte.166.11.1173 · Cited by 286
Singh, H., Thomas, E. J., Mani, S., Sittig, D., Arora, H., Espadas, D., Khan, M. M., & Petersen, L. A. (2009) · Archives of Internal Medicine · doi:10.1001/archinternmed.2009.263 · Cited by 212
Metadata
- Authors
- Gandhi, T. K.
- Affiliations
- Brigham and Women's Hospital (US)
- Corresponding author
- Gandhi, Tejal K.
- ORCID
- Gandhi, Tejal K.
- Venue
- Annals of Internal Medicine
- Publisher
- American College of Physicians
- Published
- 2005-03-01
- Volume
- 142
- Issue
- 5
- Pages
- 352-358
- ISSN
- 0003-4819 (ISSN-L)
- 1539-3704
- OpenAlex
- W2013795407
- Cited by
- 246
- References
- 19
- Citations by year
- 2026: 1 · 2025: 7 · 2024: 3 · 2023: 2 · 2022: 3 · 2021: 9 · 2020: 11 · 2019: 7 · 2018: 9 · 2017: 5 · 2016: 10 · 2015: 13 · 2014: 13 · 2013: 19 · 2012: 15
- FWCI
- 21.71
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Annals of Internal Medicine (publishedVersion)
- PubMed (publishedVersion)
- Funders
- California Health Care Foundation
- Topics
- Health Sciences › Nursing › Leadership and Management › Hospital Admissions and Outcomes
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Patient Safety and Medication Errors
- Health Sciences › Medicine › Family Practice › Clinical Reasoning and Diagnostic Skills
- Keywords
- delayed diagnosis, laboratory abnormalities, handover, continuity of care, information technology, patient safety, tuberculosis diagnosis
- MeSH terms
- Aged, Communication, Continuity of Patient Care, Cough, Diagnostic Errors, Hospitals, Teaching, Humans, Male, Patient Care Team, Tomography, X-Ray Computed, Tuberculosis, Pulmonary, United States, Weight Loss, Fatal Outcome, Pneumonia, Bacterial
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