Fumbling the handoff.(Practice Trends)

Every day, millions of patients are transferred between and among primary care physicians and specialists in laboratories, hospitals, nursing homes, and outpatient care. Each "handoff" carries the risk of a fumble in which vital patient information is lost.

In this excerpt from their book, Dr. Wachter and Dr. Shojania tell the story of Joe Silber, a 43-year-old mechanic and racquetball player, who went to a hospital emergency room with chest pains. The ER doctor ordered an x-ray along with ECGs and other tests.

Twelve hours later, unaware that an x-ray had been ordered, another doctor discharged Mr. Silber with a clean bill of health:

 
  "Meanwhile, the hospital's radiologist had reviewed the x-ray and 
  noticed a small lung nodule. In the old days, radiologists waited to 
  be asked about results. However, after a slew of big malpractice suits 
  involving unreported mammogram abnormalities, radiologists are now 
  proactive in making sure somebody, somewhere gets the word-especially 
  when dealing with biggies, like potential breast and lung cancer. In 
  this case, since the discharging attending was not the patient's 
  ...