Fumbled Handoffs: One Dropped Ball after Another

View larger version (20K): [in a new window]   Figure 1. Timeline of events. CT = computed tomography.

View larger version (36K): [in a new window]   Figure 2. Communicating critical test results: Creating a fail-safe process.

View larger version (53K): [in a new window]   Figure 3. Screenshot of results manager. Screenshot of a results management application that tracks patients with test results and shows results as they return, prioritized on the basis of whether a result is normal or abnormal. This application can also be used to generate and print letters to patients.