Communicating Critical Findings—A Three–Part Series
Part 1: Radiology to ED
CME Information
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NORCAL Mutual Insurance Company, a member of the NORCAL Group. The NORCAL Group of companies includes NORCAL Mutual Insurance Company, Medicus Insurance Company and FD Insurance Company.
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Original Release Date: January 15, 2017
Expiration Date: February 1, 2019
Learning Objectives
By reviewing medical professional liability claims and/or emerging topics in healthcare risk management, this enduring material series will support your ability to:
Assess your practice for risk exposures.
Apply risk management best practices that increase patient safety and reduce medical professional liability claims.
Target Audience
Radiologists, administrators and other physicians and staff who order radiology studies.
Credit Designation Statement
NORCAL Mutual Insurance Company designates this enduring material for a maximum of 1 AMA PRA Category 1 Credit. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
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As an ACCME accredited provider, NORCAL Mutual Insurance Company requires planners, reviewers or authors who influence or control the content of a CME activity to disclose financial relationships (of any amount) they have had with commercial interests associated with this CME activity during the year preceding publication of the content.
Any identified conflicts of interest are resolved prior to the commencement of the activity.
Disclosures
Individuals involved in the planning, reviewing or execution of this activity have indicated they have no relevant financial relationships to disclose.
Editor
Mary–Lynn Ryan
Risk Management Specialist,
NORCAL Mutual
Content Advisors
Jaan E. Sidorov, MD
Chair, NORCAL Mutual, FD Insurance and Medicus
Patricia A. Dailey, MD
Director, NORCAL Mutual, FD Insurance and Medicus
Rebecca J. Patchin, MD
Director, NORCAL Mutual, FD Insurance and Medicus
William G. Hoffman, MD
Family Practice Content Advisor
Failure to communicate critical radiology findings in a timely manner is a frequent basis of malpractice allegations against radiologists.1
To ensure timely delivery of critical radiology findings to referring emergency department (ED) clinicians, everyone involved must consider the entire communication loop. The process starts when the ED clinician orders an imaging examination, and continues when radiology personnel create the images. The next piece is the communication of the results. The conclusion of the process occurs when the referring ED clinician receives and confirms receipt of the findings.2 A break at any point in the communication loop can result in communication delay, diagnosis delay, patient injury and the filing of a lawsuit.
Judging from malpractice plaintiffs’ allegations and referring physicians’ testimony in NORCAL closed claims, there is an expectation that radiologists will directly communicate critical findings to the referring ED physicians in a timely manner. This apparent focus on radiologists as the party responsible for pushing critical results out (as opposed to the ED physician being responsible for pulling the results in) is apparent in Joint Commission National Patient Safety Goal NPSG.02.03.013 and in the American College of Radiology Practice Guideline for Communication of Diagnostic Imaging Findings.4 This is not to say that diligence and hard work by radiologists will guarantee timely treatment of a critical condition, or that no one else shares in the responsibility of timely critical results communication. As the case studies in this article demonstrate, everyone in the communication loop can contribute to the success or failure of critical results reporting.
Although this article focuses on radiologist and radiology department/group administrator strategies for timely reporting of critical results to referring ED clinicians, any individual involved in the critical result communication loop between the radiology and emergency departments can use the critical result communication strategies presented to increase patient safety and reduce liability risk exposure.
The March and April 2017 Claims Rx articles are parts two and three of this critical findings series. Part two will address the communication of critical findings between pathologists and surgeons/dermatologists and part three will address the responsibilities of primary care physicians who receive critical findings.
In the following case study, the radiologist’s critical finding was not communicated to the ED physician in time to treat the patient before progression of his condition resulted in permanent injury. Like so many other adverse outcomes, this one was caused by a combination of systems and human errors: The critical results communication policies and procedures were inadequate, the radiologist misunderstood his direct communication duties and the ED physician forgot to check for the radiology results when he hadn’t heard from the radiologist after a few hours. Consider how better communication policies and practices could have averted the poor outcome in the following case.
Case One
Allegation:
The radiologist’s failure to communicate an ultrasound finding of testicular torsion contributed to delayed treatment and loss of the testicle.
A patient was transported to the ED by ambulance due to sudden and significant pain in his left testicle. During triage, the nurse noted that the patient’s testicle was mildly swollen and very tender to light palpation. The patient reported his pain was a nine on a scale of one to 10. Testicular torsion and acute epididymitis were in the ED physician’s differential diagnosis. He ordered an ultrasound to rule out testicular torsion, as well as IV morphine and warm compresses. The ultrasound demonstrated testicular torsion, which the radiologist noted in his report. The radiologist dictated his report, reviewed the transcription and saved it in the electronic health record (EHR) within 30 minutes of the ultrasound’s completion. The radiologist did not directly communicate the results to the ED physician. Several hours later, the ED physician reviewed the report, but it was too late to save the patient’s testicle. The patient sued the ED physician, radiologist and hospital for delayed diagnosis of testicular torsion.
Experts believed the patient’s testicle could have been saved if surgical detorsion had occurred immediately following the detection of the positive ultrasound finding. The radiologist assumed his timely entry of the radiology report into the EHR satisfied his communication duties. Unfortunately, the ED physician was relying on the radiologist to alert him directly to a critical finding. The hospital had a critical result reporting policy, but the radiologist had not reviewed the policy to the extent necessary to understand he should have directly communicated the finding of testicular torsion back to the ED physician as soon as it was discovered.
The final report is the definitive record of an imaging examination; however, the criticality of a finding may require the radiologist to contact the ordering physician directly prior to the delivery of the final report. Different levels of urgency may require different methods of communication.5 According to the American College of Radiology (ACR), non–routine communications should be handled in a manner “most likely to reach the attention of the treating or ordering physician/health care provider in time to provide the most benefit to the patient.”4 Posting a critical result solely in the EHR will rarely fulfill this objective.
The Joint Commission requires “timely” intervention and provision of results within an established timeframe so the patient can be promptly treated;3 but it suggests that institutions define for themselves what is timely for a given imaging finding.5
Many organizations have developed algorithmic approaches to reporting and communicating critical radiology results based on lists of critical findings.6 Some specify color codes for different levels of urgency (e.g., red–level findings must be communicated directly to the ordering physician); others name different levels of urgency (e.g., “critical” vs. “urgent” vs. “significant”). The ACR formed the Actionable Reporting Work Group to address the potential role of information technology (IT) in the communication of imaging findings, especially in cases involving critical findings. The work group defines three categories of actionable findings:5
Categories of Actionable Findings
Regardless of categories of urgency, radiologists should strive to deliver results to referring physicians as rapidly as possible, without compromising quality and accuracy.7
Chart based on: Larson PA, et al. Actionable Findings and the Role of IT Support: Report of the ACR Actionable Reporting Work Group. J Am Coll Radiol 2014;11:552–558. Available at: www.jacr.org... (accessed 11/22/2016).
The Joint Commission requires accredited facilities to define critical results.3 The ACR recommends “non–routine communication” (i.e., action in addition to a final radiology report) when findings:4
“Suggest a need for immediate or urgent intervention”
“Are discrepant with a preceding interpretation of the same examination and where failure to act may adversely affect patient health”
“May be seriously adverse to the patient’s health and may not require immediate attention but, if not acted on, may worsen over time and possibly result in an adverse patient outcome”
Testicular torsion is a critical result and it requires immediate or urgent intervention.8
A critical results list can facilitate clinical decision–making and communication between radiologists and ED physicians. An example of critical findings listed by level of criticality, developed by the ACR Actionable Reporting Work Group, can be accessed at: www.jacr.org... (accessed 11/18/2016). These lists are not meant to be definitive.5 The length of the list should be carefully considered. A long, very detailed list can be difficult to monitor and follow. If it is too complex for compliance, it loses its value as both a patient safety and risk management tool.
Creating Critical Results Communication Policies and Procedures
The policies and procedures for communicating critical results should allow the radiologist to answer the following questions:4,9
What is the criticality of the finding?
How much time do I have to report it?
To whom should the finding be communicated?
To whom should the results be communicated when the ordering clinician is not available?
How should the finding be communicated?
Has the information been received by the person who can best act on it?
Consider the following recommendations:2,3,4,6,10
Create a critical results list and define different levels of criticality.
Involve radiologists and emergency physicians in the creation of critical findings lists.
Avoid creating a list that is too difficult to use because of its length and detail.
Take into consideration the prevalence of findings based on the patient population.
Analyze and revise the list regularly to reflect changing practice patterns and disease incidence.
Treat the critical findings list as a floor, not a ceiling.
Physicians should feel free to use their clinical judgment in determining whether communicating a finding not on the list should be expedited.
Ensure anyone who is involved in ordering and communicating ED patient radiology results is aware of what is on the critical results list and knows how to access it.
Define the acceptable length of time between the availability and communication of different categories of critical results.
Define acceptable methods of communication for each category of critical results.
Include clear identification and read–back directions for spoken transactions, for example:
Identify yourself.
State the emergency nature of the call.
Verify the identity of the person receiving the result.
State the name of the study and the critical results.
Request a read–back of the patient’s name and critical results.
Document the interaction, including the date, time and names of both parties.
Identify where spoken critical result communications should be documented (e.g., PACS, final radiology report, log).
Define by whom and to whom critical results should be reported.
Outline the information that should be included in documentation of direct critical result communication, including:
“Critical result” as a lead off to the documentation
The name of the person to whom the results were reported
The date and time
The method of communication
What was discussed
An assertion the communication was understood
Identify who should receive the results if the ordering clinician is not available.
Monitor and evaluate critical results communication procedures.
Determine whether critical results are being communicated in the timeframes designated in the policy.
Delayed communication of critical result claims frequently involve radiologists who fail to close the communication loop (i.e., fail to obtain an acknowledgement that the ED physician read and understood the finding). Closing the loop may seem redundant because radiology reports can often be created, finalized and posted in the EHR in near real–time;2 however, redundancy in a system increases patient safety and reduces malpractice risk. It is particularly important in high–risk interactions, such as communication of critical results between radiology and emergency departments. In the following case, the radiologist assumed the ED physician, who had ordered a STAT head CT scan, would access his preliminary report from the EHR, but the preliminary report was never saved to the system. If the radiologist had directly contacted the ED physician with his preliminary findings, the patient may have received life–saving treatment.
Case Two
Allegation:
The radiologist negligently failed to communicate his CT scan findings to the ED physician.
The radiologist opened a STAT head CT scan to evaluate for brain injuries following head trauma. He believed the images showed a possible intracranial hemorrhage and quickly dictated a report recommending further studies. He tried to call the ED, but was put on hold. He finally hung up the phone and went to work on his other reports. (It was his understanding the ED physician would be able to retrieve his transcribed report in the system within minutes.) Either because the radiologist failed to save his work at some point, or because the EHR system malfunctioned (the radiologist was aware of “glitches” in the EHR system causing reports to occasionally disappear), the report was not available when the ED physician looked for it in the EHR.
According to ED policies and procedures, ED physicians were required to obtain the results of any radiology studies suggestive of brain injury prior to consulting with a neurosurgeon for head trauma. Prompted by the patient’s family, who had been waiting for the results of the CT scan for several hours, the ED physician contacted the radiology department to ask why the report was not in the system. He was told the images had been reviewed, but no report was in the system. By this time, the radiologist who had first interpreted the images had gone off shift, so the ED physician requested a second interpretation of the CT scan. Based on the second radiologist’s findings, which were identical to those of the first radiologist, the ED physician ordered additional studies and requested a neurosurgery consult. As the patient was being transported for additional studies, he coded and could not be revived. His death was attributed to a subdural hematoma. The patient’s family filed a lawsuit against the ED physician, hospital and radiologist. They alleged the delay in communication of the findings on the CT scan to the ED physician was negligent and delayed the diagnosis and treatment of the patient’s brain hemorrhage, which would have been treatable if diagnosed in a timely manner.
The radiologist’s failure to directly contact the ED physician with his findings significantly complicated the radiologist’s defense in this case. In the first place, the CT scan was ordered STAT and the findings were critical. According to hospital and radiology group policy, the radiologist should have directly communicated the findings to the ordering physician within an hour. Because there was a slight possibility the initial report would not be available to the ED physician because of known EHR problems, the radiologist should have made an extra effort to reach the ED physician, instead of assuming the ED physician could access the report for himself. Although it may have been difficult getting through, it was the radiologist’s responsibility to directly communicate the results to the ED physician. The ED physician’s inexplicable and indefensible delay in following up on the results and the hospital’s failure to solve the problem with its EHR system also contributed to the adverse outcome but did not excuse the radiologist’s contribution to the treatment delay.
Radiologists should ensure critical results are received and understood by a clinician who can act on them for the patient’s benefit. Loading a report into the EHR does not close the communication loop. Consider the following recommendations:2,3,4,6,10
Communicate critical findings pursuant to hospital/practice communication policies when appropriate and work with the administration to make the protocols more effective if necessary.
If protocols or policies are ambiguous, seek clarification.
Follow clinical guidelines for reporting findings (e.g., the ACR Practice Parameter for Communication of Diagnostic Imaging Findings) when appropriate.
Err on the side of caution with critical results communication. If a finding requires urgent intervention, inform the ED physician by telephone without delay.
Identify yourself.
State the emergency nature of the call.
Verify the name of the person receiving the report.
Provide the name of the test and the test results.
Ask the person receiving the report to read back the patient’s name and the critical result.
Document the actual (or attempted) direct communication with the ED physician, designated ED physician proxy or patient. Place that documentation in the diagnostic report or in the location designated in the critical results policy.
Documentation should include (at a minimum):
“Critical Result” as a lead off to the documentation
The name of the person to whom the results were reported
The date and time
The method of communication
What was discussed
An assertion the communication was understood
Customize critical result documentation “macros” to include appropriate elements of documentation.
One way hospitals and imaging departments can reduce the risk of delayed communication of critical results is by implementing an electronic critical test results management (CTRM) system. CTRM software, also referred to as critical tests reporting and closed–loop reporting software, helps prevent delayed communication of critical results. For example, some systems alert the proper physician directly when a critical result is discovered by the radiologist, while others alert administrators who facilitate direct communication between the radiologist and referring physician. These systems can help radiologists close the communication loop.9
As the previous case examples show, the criticality of radiology results may require direct communication between the radiologist and ED physician. Another aspect of communication between radiology and the ED is the radiology report itself. ED physicians may rely on radiology reports — in addition to or as an alternative to the information the radiologist communicates directly to the ED — to make treatment decisions.8 In the following case, the radiologist’s passive attitude and ambiguous report contributed to the delay in treating the patient’s critical condition. Consider the different ways this adverse outcome could have been avoided by better communication between the radiologist and ED physician.
Case Three
Allegation:
The radiologist’s failure to appreciate and communicate spinal infection to the ED physician resulted in delayed diagnosis and treatment culminating in below–the–waist paralysis.
A 52–year–old female patient with a history of spinal osteoarthritis presented to the ED complaining of 9/10 back pain. The pain was so severe, she was unable to stand or walk. She also reported hip pain and a burning and tingling sensation in her legs. Her temperature was normal and she reported no trauma. She was given pain medication, which reduced her pain to 8/10. This information was documented in the triage and nursing notes. The ED physician documented a relatively normal, though incomplete, neurological assessment — she did not assess whether the patient was able to walk — and ordered a CT scan of the lumbar spine.
The CT scan was completed and the radiologist entered a preliminary report in the EHR within an hour. The report findings focused on severe degenerative changes to the patient’s vertebrae. In addition to degenerative disc and facet disease, he concluded “a pathologic process cannot be excluded,” but also concluded there was no obvious acute abnormality.
The ED physician reviewed the preliminary report and concluded the arthritis was causing the patient’s pain. She noted the patient’s pain had improved with medication (though she did not notice that the pain had only improved from a 9/10 to an 8/10). She also didn’t realize the patient was unable to walk because of the pain. Therefore, she discharged the patient with instructions to follow up with her primary care physician and return if the pain worsened. The following day, the patient was transported by ambulance to a different hospital where studies indicated a spinal abscess was impinging on her spinal cord. Despite undergoing immediate surgery, she never regained use of her lower body. She filed a lawsuit against the first hospital, ED physician and radiologist.
In many claims involving critical results reporting between the radiology and emergency departments, it is difficult for defendants to avoid blaming each other for the patient’s injury. In this case, the hospital, ED physician, and radiologist blamed each other for the delay in diagnosing the spinal infection, with each claiming they had met the standard of care. For example, the radiologist argued that the ED physician should have obtained a full history of the patient’s symptoms and should have ordered a different study than a CT scan, which was not the optimal modality for diagnosing a spinal infection. The radiologist further believed that the ED physician, after accessing the preliminary findings in the EHR, should have initiated discussions with him about whether the patient needed further work–up. Finally, the radiologist believed the order for the CT scan was incomplete and his findings and impressions were reasonable explanations for lower back pain. In other words, if the order had included the patient’s pain level and her inability to walk, the radiologist would have been more likely to suspect infection and would have specifically included it in his impressions. However, expert support of the terminology in the radiologist’s report and whether he had a duty to contact the ED physician was mixed. A primary point of contention was the defendant radiologist’s use of the phrase “a pathologic cause cannot be excluded” instead of using “infection” or “an inflammatory change” and “destruction” of the bone. Experts also faulted the radiologist for failing to identify the location of “the pathological process.” There was also conflicting expert testimony regarding whether the standard of care required the radiologist to recommend an MRI, which would have been the appropriate method for diagnosing the spinal infection. Short of a recommendation, a number of the radiology experts believed the defendant radiologist could have prompted the ED physician to order an MRI by using less ambiguous language in his impressions.
Radiologists should pay careful attention to the wording, format and structure of their reports to ensure the reports convey their findings, impressions and recommendations as understandably and efficiently as possible.7
Structure
The ACR recommends a structured format for radiology reports that includes stating imaging findings in the body of the report and specific diagnoses in an ‘impression’ section.11 Despite the guideline, there is considerable variability in which section of the report radiologists state critical findings. If the critical finding is in the body of the report instead of the impression section, which is where referring physicians often focus, critical findings can be overlooked.4,11
Word Choice
Ambiguous words can delay interventions.11 Phrases and words that signify degrees of probability (e.g., “probable,” “consistent with,” “likely,” “suggestive,” etc.) may be given more or less weight by the referring physician than intended.12 “Cannot exclude” and “correlate clinically,” without a detailed explanation, can leave a referring physician without the information he or she needs to make treatment decisions. ED physicians rely on radiologists for their expertise in interpreting findings. Ambiguous phrases can put the onus on the referring physician to interpret the findings.13
Radiology Report Writing
Consider the following recommendations:7,13,14,15
Be concise.
List the most important findings first.
Create reports with separate “Findings” and “Impression” sections
List critical findings in both the “Impression” and “Findings” sections of the report.
Choose unambiguous words and terms.
Interpret your findings.
Comment on the quality of the image if it affects your interpretation.
Comment on the limitations of the examination.
If limitations can be solved by reviewing the patient’s medical record or discussing the patient with the referring physician, do so.
Make recommendations for further investigations.
Be careful when editing your transcriptions.
Before saving a report to the system, stand in the shoes of the referring physician who will rely on the report. Assess whether the report at least has clearly answered the following four questions:
What did you see?
What do you think the findings mean?
What do you want the referring physician to conclude from your report?
What do you think the referring physician should do next?
Often, when a patient comes to the ED, radiographic studies are interpreted by an on–site radiologist after the patient has been discharged or after the ordering ED physician has gone off shift. Consider how this outcome could have been different if the radiologist or ED staff had followed critical results policies and procedures.
Case Four
Allegation:
Failure to communicate chest x–ray findings resulted in the patient’s pneumonia going untreated and ultimately causing his death.
A 25–year–old man presented to the ED complaining of chest pain, difficulty breathing and coughing. The ED physician ordered a chest x–ray. The radiologist identified a round infiltrate in the upper lobe of his left lung. His differential diagnosis was round pneumonia versus inflammatory etiology versus neoplasm. The radiologist recommended close follow–up but did not flag the report as containing a critical finding and did not contact the ED physician to report his findings.
The patient was discharged with a diagnosis of “pleuritic chest wall pain” before the ED physician reviewed the chest x–ray report. The discharge summary mistakenly indicated the chest x–ray was negative. No one contacted the patient to tell him he had pneumonia. He died a week later. Autopsy revealed bilateral empyema and pulmonary abscesses. His family filed a lawsuit against the radiologist, ED physician and hospital.
The hospital critical results reporting policy was consistent with the recommendations contained in the ACR Actionable Reporting Work Group (see the discussion of the ACR Actionable Reporting Work Group recommendations following Case One). Pneumonia was on the list of Level 2 critical results that required communication of the findings with the referring physician “within hours.” The radiologist did not follow the critical results reporting policy; had he done so, he most likely would have reached the ED physician before he discharged the patient with an incorrect diagnosis. A redundant system was in place in which ED policy required culling the final x–ray reports and determining whether they were congruent with the discharge summary; unfortunately, that procedure was not followed either. Even the best patient safety policies and procedures won’t work if clinicians and staff do not comply with them.
Communication process delays may result in patients being discharged from the ED with a preliminary diagnosis that is later corrected. By the time the discrepancy is discovered, the patient, ED physician and radiologist may not be on the premises. There should be an airtight protocol for communicating these findings, including contacting the patient, if necessary. Radiology and emergency departments must coordinate policies and procedures to ensure critical findings are communicated in these circumstances. Consider the following strategies to help close potential communication gaps:4
Emergency Department Administrators
Standardize the method of identifying ED/radiology discrepancies and delineate an action plan for responding to them.
Evaluate whether critical findings are being communicated to referring ED physicians by radiologists in a manner consistent with hospital policy; if not, address issues at an administrative level.
Ensure that all critical results telephone communications are documented and include names of the individuals on the call, the date and time of the communication and what was discussed.
Ensure discrepant results are communicated to the patient’s primary care physician or the patient.
Consider dedicating a staff person to make follow–up calls to patients whose radiology or lab reports are not congruent with the initial diagnosis in the ED.
Radiology Administrators
Establish communication policies and procedures that identify to whom critical findings should be communicated when the ordering clinician is not available.
Every individual in the communication loop must fulfill their role in the process of delivering a critical result to the individual in the best position to act on it. Policies give the communication process structure. When critical results communication policies are ignored, particularly when the patient has come to the emergency department with a critical condition, the risk of patient injuries increases, as does liability risk.
In many lawsuits involving delayed diagnosis and treatment of critical conditions in emergency department patients, the plaintiff claims the radiologist should have expediently called the referring physician and reported the critical finding. The radiologists in these cases have usually failed to close the communication loop. Radiologists and ED physicians have differing opinions about communication responsibilities. However, radiologists can increase patient safety and decrease liability risk with timely, direct reporting of critical results to referring ED physicians, even when the results are available in the EHR. Redundancy in communication systems increases patient safety and reduces malpractice liability risk. It is worth the extra effort.
| Specials thanks to Jonathan D. Clemente, MD; Bradley J. Bohnert, MD; Nina Kottler, MD and Upma Rawal, MD for reviewing this article.
The NORCAL documents referenced in this article, along with many other Risk Management Resource documents and past editions of the Claims Rx, are available in the Risk Solutions area of MyACCOUNT, or by policyholder request at 855.882.3412.
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Larson PA, et al. Actionable Findings and the Role of IT Support: Report of the ACR Actionable Reporting Work Group. J Am Coll Radiol. 2014;11:552–558. Available at: www.jacr.org... (accessed 11/22/2016).
Babiarz LS, et al. Neuroradiology Critical Findings Lists: Survey of Neuroradiology Training Programs. AJNR. 2013;34:735–739. Available at: http://www.ajnr.org... (accessed 11/22/2016).
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Martino A. Getting the Message: How Can Radiologists Best Communicate Critical Test Results? 2015. ACR Bulletin. Available at: https://acrbulletin.org... (accessed 11/22/2016).
Trotter SA, et al. Determination and Communication of Critical Findings in Neuroradiology. J Am Coll Radiol. 2013;10(1):45–50.
Gershanik EF, Lacson R, Khorasani R. Critical Finding Capture in the Impression Section of Radiology Reports. AMIA Annu Symp Proc. 2011; 465–469. Available at: www.ncbi.nlm.nih.gov... (accessed 11/22/2016).
Baker M. Radiology research tackles squishiness of wordiness: When radiologists share their findings with clinicians, the meaning may be fuzzy. 2003. Stanford Report. Available at: http://news.stanford.edu... (accessed 11/22/2016).
Jones J. The Perfect Radiology Report. 2016. ACR Bulletin. Available at: https://acrbulletin.org... (accessed 11/22/2016).
Gurney JW. How to Compose a Radiology Report. Chest X–ray.com. 2014. Available at: www.chestx–ray.com... (accessed 11/22/2016).
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