Breakdowns in communication of radiological findings: an ethical and medico-legal conundrum

Collaborating with non-radiological clinical colleagues

Paediatric radiology is a challenging and intriguing subspecialty, dealing with children, guardians and non-radiological clinical colleagues. Paediatric radiologists are routinely in contact with numerous paediatric and surgical subspecialties, all having different needs, perceptions, prioritisations and expectations. Moreover, the radiologist is part of the team of radiographers, sonographers, nurses and secretaries, assisted by appropriate equipment and electronic tools. The framework of good collaboration to ensure safety and effectiveness for the imaged child is a shared responsibility among all medical practitioners involved. Communication in routine practice has many forms and includes appropriately filled radiology requests in accordance to the patient's medical records, routine and timely production of structured, problem-solving radiology reports, face-to-face or electronic-assisted communications and discussions on a pre-defined framework, mutually-agreed and evidence-based protocols adjusted to local availability, skills and national and international guidelines. Mutual understanding of advantages and limitations of imaging is paramount. Well-meant discussions, professionalism and empathy should promote soft skills, bidirectional communication and good collaboration for the benefit of added-value paediatric radiology. International societies, health authorities, medical directors and senior consultants have the responsibility to suggest and safeguard frameworks and recommendations. Regular multidisciplinary meetings and multidisciplinary research projects under openness, honesty and transparency are pathways favouring good collaboration.

How breast radiologists can deal with the disruptive technologist

Physician burnout continues to be a challenge in addressing radiologist wellness. The stressors contributing to breast radiologist burnout are distinctive due to the unique work environments of a breast center. The intimate nature of a subspecialized team of radiologist(s) and technologists at an imaging center may result in interpersonal challenges such as a disruptive technologist. It is important to address the stressors to mitigate the increasing burnout affecting breast radiologists. This article raises awareness among radiologists and administrators and provides strategies to breast centers and breast radiologists for guidance on dealing with a disruptive technologist.

Malpractice Lawsuits Relating to Mechanical Thrombectomy for Acute Ischemic Stroke: A Systematic Review

Background and Purpose

Medical-legal claims for malpractice relating to the use of alteplase for acute ischemic stroke (AIS) are usually for failure to treat rather than for complications. The advent of mechanical thrombectomy (MT) as a standard of AIS treatment has added a new dimension to the medical-legal landscape as there is a need for the delivery of a higher level of care creating the potential for delays and errors associated with such treatment. Information on causes of malpractice related to mechanical thrombectomy (MT) is currently lacking.

Methods

We conducted a systematic review of legal databases (Westlaw, LexisNexis, Google Scholar Case Law, and VerdictSearch) to identify medical malpractice cases with and without verdicts filed in the United States up to March 31, 2021 which pertained to performance or non-performance of MT for AIS. We collected various case characteristics, case outcomes, and root causes for malpractice claims.

Results

We found 25 cases, 16 of which alleged failure to treat with MT, 8 for harm due to delay in treatment and 1 case that alleged complications. Root causes included delay in vascular imaging, communication breakdowns, and transportation delays. Eight cases had an outcome in favor of the defendant, 9 in favor of the plaintiff, and 8 remained to be determined.

Conclusions

As with alteplase, malpractice allegations regarding MT for AIS are largely for failure to treat or delay in treatment as opposed to complications. Addressing root causes of diagnostic delay, communication breakdowns, and transportation delays may reduce subsequent malpractice risk.

Evaluating Radiology Result Communication in the Emergency Department

PURPOSE

To assess the pattern of result communication that occurs between radiologists and referring physicians in the emergency department setting.

METHODS

An institutional review board-approved prospective study was performed at a large academic medical center with 24/7 emergency radiology cover. Emergency radiologists logged information regarding all result-reporting communication events that occurred over a 168-hour period.

RESULTS

A total of 286 independent result communication events occurred during the study period, the vast majority of which occurred via telephone (232/286). Emergency radiologists spent 10% of their working time communicating results. Similar amounts of time were spent discussing negative and positive cross-sectional imaging examinations. In a small minority of communication events, additional information was gathered through communication that resulted in a change of interpretation from a normal to an abnormal study.

CONCLUSIONS

Effective and efficient result communication is critical to care delivery in the emergency department setting. Discussion regarding abnormal cases, both in person and over the phone, is encouraged. However, in the emergency setting, time spent on routine direct communication of negative examination results in advance of the final report may lead to increased disruptions, longer turnaround times, and negatively impact patient care. In very few instances, does the additional information gained from the communication event result in a change of interpretation?

Improving Communication Delay of Outpatient Sleep Study Results to Pediatric Otolaryngology Patients and Families

Objective

We undertook this quality improvement project to improve communication of outpatient pediatric sleep study results to families in a consistent and timely manner.

Methods

Based on the Institute for Healthcare Improvement quality improvement methodology, multiple key drivers were identified, including standardizing documentation and communication for sleep study results among the otolaryngology department, sleep center, and families. Meaningful interventions included developing standard electronic medical record documentation and utilizing otolaryngology nurses and advanced practice nurses to assist with communication by sending the results from the sleep center to both the referring otolaryngology provider and the triage nurses. The primary outcome measure was the monthly proportion of sleep studies communicated by the otolaryngology department to families within 3 business days.

Results

Average monthly sleep study results communicated to families within 3 business days increased from 31% to 92.9% over the study period ( P < .0001). Sleep study results were personally communicated via telephone and voicemail in 60.88% and 34.0% of cases, respectively. Approximately 50.0% of families receiving voicemails later contacted our department for their children’s study results.

Discussion

Novel documentation strategies and involvement of our entire clinical team (physicians, nurses, and advanced practice nurses), allowed us to significantly improve the consistency and timeliness of our communication of outpatient sleep study results to families in a proactive manner.

Implications for Practice

With time-sensitive clinical test results, such as those from pediatric sleep studies, intra- and interdepartmental collaboration and standardization of the communication process and documentation may allow for more expedient care of children with suspected obstructive sleep apnea.

The fate of radiology report recommendations at a pediatric medical center

BACKGROUND

The American College of Radiology (ACR) practice parameters for communication dictate that follow-up recommendations be suggested when appropriate. Radiologists assume that referring physicians read their reports and heed their advice. In reality, recommendations might not be carried out or even acknowledged.

OBJECTIVE

We aimed to determine the proportion of imaging recommendations that are acknowledged and acted upon.

MATERIALS AND METHODS

We conducted a retrospective review of all consecutive radiology reports containing "recommend" in the impression at a single academic children's hospital over a 1-month period. We documented point of care (emergency department, inpatient, outpatient), study type, recommendation wording, and communication method (report only or direct verbal). We reviewed medical records to ascertain whether the recommendations were acknowledged or executed. We used chi-square tests to evaluate associations between variables. P<0.05 was considered significant.

RESULTS

We reviewed 526 reports and excluded 73. We included the remaining 453 reports, from 370 unique patients (201 male, 169 female). Inpatients comprised most reports (n=223), followed by emergency department (ED) patients (n=118) and outpatients (n=112). Among these reports, 69% (n=313) of recommendations were executed. Of the 140 recommendations not carried out, 14% were acknowledged in clinical notes. Compliance correlated with point of care (ED>inpatient>outpatient; P=0.001) but not with additional verbal communication (P=0.33), study type (radiograph vs. other; P=0.35) or type of follow-up recommendation (follow-up imaging vs. other; P=0.99).

CONCLUSION

Nearly one-third of radiology report follow-up recommendations are not executed. Recommendations are most commonly neglected for outpatient imaging reports. The radiology community should take steps to improve recommendation adherence.

Assigning responsibility to close the loop on radiology test results

Failure to follow-up on test results represents a serious breakdown point in the diagnostic process which can lead to missed or delayed diagnoses and patient harm. Amidst discussions to ensure fail-safe test result follow-up, an important, yet under-discussed question emerges: how do we determine who is ultimately responsible for initiating follow-up action on the tests that are ordered? This seemingly simple question belies its true complexity. Although many of these complexities are also applicable to other diagnostic specialities, the field of medical imaging provides an ideal context to discuss the challenges of attributing responsibility of test result follow-up. In this review, we summarize several key concepts and challenges in the context of critical results, wet reads, and incidental findings to stimulate further discussion on responsibility issues in radiology. These discussions could help establish reliable closed-loop communication to ensure that every test result is sent, received, acknowledged and acted upon without failure.

Development and Validation of Electronic Health Record-based Triggers to Detect Delays in Follow-up of Abnormal Lung Imaging Findings

Purpose To develop an electronic health record (EHR)-based trigger algorithm to identify delays in follow-up of patients with imaging results that are suggestive of lung cancer and to validate this trigger on retrospective data. Materials and Methods The local institutional review board approved the study. A "trigger" algorithm was developed to automate the detection of delays in diagnostic evaluation of chest computed tomographic (CT) images and conventional radiographs that were electronically flagged by reviewing radiologists as being "suspicious for malignancy." The trigger algorithm was developed through literature review and expert input. It included patients who were alive and 40-70 years old, and it excluded instances in which appropriate timely follow-up (defined as occurring within 30 days) was detected (eg, pulmonary visit) or when follow-up was unnecessary (eg, in patients with a terminal illness). The algorithm was iteratively applied to a retrospective test cohort in an EHR data warehouse at a large Veterans Affairs facility, and manual record reviews were used to validate each individual criterion. The final algorithm aimed at detecting an absence of timely follow-up was retrospectively applied to an independent validation cohort to determine the positive predictive value (PPV). Trigger performance, time to follow-up, reasons for lack of follow-up, and cancer outcomes were analyzed and reported by using descriptive statistics. Results The trigger algorithm was retrospectively applied to the records of 89 168 patients seen between January 1, 2009, and December 31, 2009. Of 538 records with an imaging report that was flagged as suspicious for malignancy, 131 were identified by the trigger as being high risk for delayed diagnostic evaluation. Manual chart reviews confirmed a true absence of follow-up in 75 cases (trigger PPV of 57.3% for detecting evaluation delays), of which four received a diagnosis of primary lung cancer within the subsequent 2 years. Conclusion EHR-based triggers can be used to identify patients with suspicious imaging findings in whom follow-up diagnostic evaluation was delayed. (©) RSNA, 2015.

Lack of timely follow-up of abnormal imaging results and radiologists' recommendations

PURPOSE

Abnormal imaging results may not always lead to timely follow-up. We tested whether certain aspects of communication in radiology reports influence the response of the referring providers, and hence follow-up on abnormal findings.

METHODS

We focused on 2 communication-related items that we hypothesized could affect follow-up: expressions of doubt in the radiology report, and recommendations for further imaging. After institutional review board approval, we conducted a retrospective review of 250 outpatient radiology reports from a multispecialty ambulatory clinic of a tertiary-care Veterans Affairs facility. The selected studies included 92 cases confirmed to lack timely follow-up (ie, further tests or consultations, treatment, and/or communication to the patient within 4 weeks), as determined in a previous study. An additional 158 cases with documented timely follow-up served as controls. Doubt in the narrative was measured by the presence of key phrases (eg, "unable to exclude," "cannot exclude," "cannot rule out," "possibly," and "unlikely"), in the absence of which we used reviewer interpretation. A physician blinded to follow-up outcomes collected the data.

RESULTS

Patients whose reports contained recommendations for further imaging were more likely to have been lost to follow-up at 4 weeks compared with patients without such recommendations (P = .01). Language in the report suggestive of doubt did not affect the timeliness of follow-up (P = .59).

CONCLUSIONS

Abnormal imaging results with recommendations for additional imaging may be more vulnerable to lack of timely follow-up. Additional safeguards, such as tracking systems, should be developed to prevent failure to follow up on such results.