According to Christopher Roy, M.D., a hospitalist at BWH who studies patient safety, “We found that while approximately half of the patients in this study had test results that were unavailable at discharge, only a very small percentage of pending results impacted the patient’s care plan.”

The researchers followed 2,644 consecutive, discharged patients from two hospitals. They found that 41 percent of patients left the hospital before all imaging and laboratory test results were reported.

Additionally, the study found: • 41 percent had 2,033 test results pending at the time of discharge. • Of the pending results, nine percent were rated “potentially actionable” by the researchers, meaning they could have altered the patient’s care plan. • Physician awareness of these “potentially actionable” results was low. Surveyed physicians were unaware of 65 potentially actionable results. • Of these 65 results, surveyed physicians agreed that 24 results required clinical action and eight results required “urgent clinical action.”

The researchers indicate that while the actual number of clinically significant test results left pending was very small, the potential for consequences to all hospitalized patients is significant. After extrapolating the findings, Roy found that in a hospital with 30,000 patients discharged per year, there could be 270 missed, actionable test results.