A 55-year-old man with cough and mild fever presented to his internist in Colorado for evaluation on a Thursday afternoon. The doctor sent the patient across the street to the hospital for a chest x-ray. Radiographs were obtained but set aside to be matched with old films. They were not read by the radiologist until Saturday morning. Unfortunately, the written report was not delivered to the referring doctor until the following Tuesday. The patient had died the night before of Legionella pneumophila. When asked why he hadn't called the results to the doctor, the radiologist replied that he had tried but couldn't get through. The case was settled for an undisclosed sum, with settlements paid by the internist, the radiologist, and the local hospital.
Case #1: A 55-year-old man with cough and mild fever presented to his internist in Colorado for evaluation on a Thursday afternoon. The doctor sent the patient across the street to the hospital for a chest x-ray. Radiographs were obtained but set aside to be matched with old films. They were not read by the radiologist until Saturday morning. Unfortunately, the written report was not delivered to the referring doctor until the following Tuesday. The patient had died the night before of Legionella pneumophila. When asked why he hadn't called the results to the doctor, the radiologist replied that he had tried but couldn't get through. The case was settled for an undisclosed sum, with settlements paid by the internist, the radiologist, and the local hospital.
Case #2: A 45-year-old nurse at a local Michigan hospital went for a routine annual chest x-ray. The occupational health nurse, placing the clinic physician's name on the x-ray request, ordered the examination. Chest x-ray revealed a 1.5-cm peripheral left upper lobe nodule, which was duly noted on the radiographic report as "suspicious." The results were filed in the patient's chart, but without the intended physician ever seeing the report.
Three years later, the patient was diagnosed with a 4.5-cm left upper lobe lung tumor. When the old records were reviewed, it was discovered that the cancer had been noted three years earlier. In discovery depositions, it was argued that the patient had been denied the opportunity to have the tumor diagnosed and treated at a stage that "more likely than not" would have resulted in excellent outcome, if not cure. The radiologist was also faulted for not making direct contact with the clinic physician, as required by American College of Radiology standards. The case was ultimately settled for over $2 million, against both the radiologist and the local hospital (the clinic physician was an employee of the hospital). Sadly, the patient died of metastatic disease before the case was resolved.
WHAT WENT WRONG?
These legal cases showcase the difficulties of communication within diagnostic radiology. No longer are standard reporting procedures considered standard of care. Offering more than standard reporting procedures is rapidly becoming mandatory to ensure that patients are followed properly. Amid generalized calls for improved patient safety in all areas of medicine, the ACR has strengthened patient safety procedures by requiring radiologists to make direct contact with referring physicians in cases of urgent and significant unexpected findings.
Communication issues have become more common and vexing with radiologists working around the clock. In an increasing number of instances, significant and/or important unexpected findings are seen by the radiologist on routine studies performed late in the evening or on weekend shifts. It is problematic or impossible in many cases to make direct contact with the referring physician during these off hours. These cases are the ones that fall through the cracks. Given enough volume, it becomes almost a statistical certainty that some critical findings will never find their way to the appropriate caregiver, at least not in time.
More insidious is the effect of PACS, outpatient imaging, and managed care on the process of physician-physician communication. Formerly, patients had a reasonable hospital stay, during which most, if not all, of their clinical issues were resolved. The imaging workup was completed on an inpatient status, without the incessant drumbeat of cost-containment and pressure to discharge the patient as quickly as possible. There was time to get results on the chart prior to discharge. When the clinical teams made rounds, they would generally pass through the radiology department to review with the attending radiologist. Issues and concerns were effectively addressed in this process, and direct communication, though not necessarily formalized or documented, was achieved on behalf of the patient. PACS, outpatient diagnostic centers, teleradiology, and new methods of offsite interpretation have led to a documented reduction in interaction between the two physician groups, resulting in potential for serious missteps.
ARTICLES AND PRECEDENTS
The courts have weighed in on the issue of communication of significant, important test results. The New Jersey Appellate Court recently indicated that the effective "communication of an unusual finding in an X-ray, so that it may be beneficially utilized, is as important as the finding itself."1 Articles in the literature have highlighted the importance of these communication errors and how they lead to heightened liability for radiologists.
In a review of Physician Insurers Association of America data, Brenner found that a significant number of malpractice claims were related to communication errors by radiologists.2 Average awards for these types of cases were much higher than for other malpractice claims. These cases were also much harder for defense attorneys to defend, as the findings were noted by the radiologist yet the system failed to act. The fault was one of communication, not interpretation.
Gandhi points out in Annals of Internal Medicine the problem of "fumbled hand-offs."3 In this paper, an elderly male patient with tuberculosis remains undiagnosed during an extended hospital stay in which he undergoes a barrage of diagnostic tests. Even though a radiologist raised the question of TB on the final chest CT report, the results were not effectively communicated to the clinical service. This resulted in delayed treatment and the eventual death of the patient, with exposure of hospital staff to active TB infection.
HOW TO IMPROVE?
Watching a radiologist in a busy hospital is all it takes to understand the genesis of these types of communication errors. All radiologists understand the need to pick up the phone and call in findings in cases of aortic injuries, brain herniations, and tension pneumothoraces. The problem becomes more complicated with less life-threatening findings: a small pulmonary nodule, small mass in the kidney, patch of pneumonia, possible hip fracture, or questionable lesion in a bone. These findings may be quite significant to the patient, but they are not emergent in the minds of most radiologists. They are so common in daily practice, it is simply not practical for a radiologist to stop and call on every case. Most radiologists expect these results to be communicated in the typed report, which eventually makes its way to the referring physician.
The problem is that the current system occasionally goes wrong in a number of ways. Every radiologist has experienced cases in which the x-ray requisition had inaccurate information, and the report was sent to the wrong physician. In some cases, the intended physician never gets the report and may not have a system to detect the problem. The physician who receives the report in error is under no legal obligation to do anything with it.
I have personally reviewed a legal case in which significant findings (a mass in the lung) were reported to the wrong physician. The physician crumpled up the report and threw it away. Upon subsequent testimony, this physician claimed that he did not know the patient and was under no obligation to follow up on the results. The trial court sided with the physician, under the premise that he had no "duty" to care for the patient.
Reports get misfiled by staff and office workers. In other cases, reports are faxed to a fax machine that is no longer working or has run out of paper. These one-way communications are fraught with potential error. We live in a mobile society where patients and doctors move, often leaving behind a trail of incomplete medical records. In an era of managed care and employment-based insurance, many patients are disrupted from their usual sources of healthcare by job changes or employers seeking more cost-effective insurance plans. In these instances, patients may no longer be allowed to have care at one facility and are suddenly referred elsewhere within our increasingly fragmented healthcare system. These are all risk factors for fumbled hand-offs and errors in critical report communication.
Similar problems exist in the hospital laboratory, where skilled technologists spend the better part of their day calling in abnormal blood chemistry results and electrolyte imbalances. These employees are in the same position as many radiologists. They have a patient with an abnormal test result and no easy way of contacting the referring physician. The same situation arises in cardiology, with patients who have abnormal ECGs or other diagnostic studies. How to let the appropriate provider know the results in a time-efficient manner?
A number of commercially available systems have been designed to help radiologists and healthcare workers manage communication of significant unexpected findings. One system uses a phone-based technique, whereby radiologists call an 800 number and dictate the important findings into a phone-based alert system. This requires dictating all the important patient information as well as the referring physician name and all contact information. Although such systems are in practice, they appear cumbersome for the busy practicing radiologist.
Brantley et al describe a computer-based system whereby a radiologist can verbally or electronically flag a report, sending the specific case to a designated individual who is then tasked with following up on the results.4 This type of system seems more workable for busy practicing radiologists, as the studies can be flagged on the fly without requiring a great deal of time to activate each alert.
Another system in development is one that I am involved with called RADAR: report alert and data accrual registry. This is a completely automated electronic alert and tracking system designed for two-way communication. By simply dictating a specified alert tag or pushing a dedicated function key, the radiologist can activate the software. The alert initiates a Web-based program that contacts the referring physician with information about the critical alert or radiologist follow-up recommendation. The referring physician can obtain results over the Web or by calling an 800 number to listen to the report findings. The process generates permanent database acknowledgement that results have been retrieved and the communication loop has been closed.
The time has come for technological advances in the field of medical communications, specifically communicating significant and unexpected findings. The era of one-way communication has come to an end. New and innovative systems can supplement traditional reporting to provide advanced methods of critical alert communications. With the correct systems in place, radiologists can quickly and efficiently prioritize important findings and effectively communicate them to referring providers, while providing electronic acknowledgement of closed-loop communications.
In promoting improved systems of medical communication, radiologists protect themselves, their hospitals, and ultimately the health and safety of the patients they serve.
1. Jenoff v Gleason, 521 A2d 1323 (NJ App. 1987).
2. Brenner RJ. Communication errors in radiology: a liability cost analysis. J Am Coll Radiol 2005;2:428-431.
3. Gandhi TK. Fumbled handoffs: one dropped ball after another. Ann Intern Med 2005;142:352-358.
4. Brantley SD, Brantley RD. Reporting significant unexpected findings: the emergence of information technology solutions. J Am Coll Radiol 2005;2:304-307.
Dr. Chesbrough is president of Radiology Medical Consultants in Bloomfield Hills, MI, (firstname.lastname@example.org) and is a staff consultant at Henry Ford Health System in Detroit.