Due to communication errors within American hospitals, many patients suffer consequences from delayed communication of critical test results and significant, unexpected findings. This issue of "fumbled communication hand-offs" was a major issue cited by the Institute of Medicine report to Congress in 1999 documenting more than 100,000 patient deaths occurring each year in the nation's hospitals and healthcare institutions due to provider errors.
This problem has reached such significant proportion that The Joint Commission's No. 2 National Patient Safety Goal for 2008 is "to improve the effectiveness of communication among caregivers," for the fifth straight year. Additionally, the American College of Radiology in 2005 re-issued its guidelines for communication and included the principles that "communication is a critical component of the art and science of medicine and is especially important in diagnostic radiology" Documentation of direct communication is recommended. In those situations [that] constitute significant unsuspected findings, the interpreting physician or his/her designee should communicate the findings to the referring physician, other healthcare provider, or an appropriate individual in a manner that reasonably insures receipt of findings."
While modern medicine provides amazing and sophisticated diagnostic imaging technology, the delivery systems for test results have not kept pace. Communication errors continue to represent a significant challenge for healthcare institutions across the enterprise. All too often, significant, unexpected findings are not relayed to the appropriate provider via traditional reporting methods. The greatest diagnostic tools mean little to the patient if his or her test findings are not communicated effectively. The healthcare industry is just now realizing the importance of this component of quality healthcare delivery, calling it Critical Test Result Management.
Legal cases
Case 1: A 55-year-old man presented to his internist with cough and fever on a Thursday afternoon. The doctor sent the patient across the street to the hospital for a chest x-ray. Radiographs were obtained but not read by the radiologist until Saturday morning, at which time the radiologist noted, "bilateral pneumonia, follow-up recommended." Unfortunately, the written report was not delivered to the referring doctor until the following Tuesday. The patient died the night before of Legionella pneumonia. When asked, at deposition, 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 healthcare worker went to her local hospital for a routine annual chest x-ray. The occupational health nurse ordered the examination, writing the clinic physician's name on the x-ray request. The chest x-ray revealed a 1.5-cm left upper lobe nodule, which was 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 more than $2 million against both the radiologist and the local hospital (the clinic physician was an employee of the hospital).
Scope of the problem
Every radiologist has experienced cases in which the x-ray requisition had inaccurate information or 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.
Watching a busy radiologist for a day is all it takes to understand the genesis of these types of communication errors. While almost 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 non-immediate findings: a 1cm pulmonary nodule, a 2.5cm mass in the kidney, pneumonia, hairline 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. And they are so common that it is simply not practical for a radiologist to call on every case.
Staff and office workers misfile reports. 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?
With 6,500 hospitals and tens of thousands of medical clinics throughout the United States, there is a significant risk management and patient care issue, as well as an accreditation issue for The Joint Commission. The above legal cases showcase the difficulties of communication within diagnostic radiology. No longer are routine reporting procedures considered standard of care. Offering additional back-up communications is rapidly becoming mandatory to ensure that patients are followed properly.
More insidious is the effect of picture archiving and communications systems, 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. Today, PACS, outpatient care, teleradiology, and offsite interpretation has led to a documented reduction in interaction between the two physician groups, resulting in potential for serious missteps.
Rising standards
Amid generalized calls for improved patient safety in all areas of medicine, communication issues have become more frequent with radiologists working around the clock and in remote areas of the world. In an increasing number of instances, the radiologist, on routine studies performed late in the evening or on weekend shifts, sees significant and/or important unexpected findings. It is almost impossible to make direct contact with the referring physician during these off hours. These cases are often the ones that fall through the cracks. Given enough volume, it becomes probable that critical findings will never find their way to the appropriate caregiver, at least not in time. At the same time, the ACR and other national organizations have strengthened patient safety procedures by requiring radiologists to make "direct" or additional contact with referring physicians in cases of urgent and significant unexpected findings.
The courts have weighed in on the issue of communication of 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." 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, R. James Brenner found that a significant number of malpractice claims were related to communication errors by radiologists. 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.
Tejal K. Gandhi, MD, points out in Annals of Internal Medicine the problem of "fumbled hand-offs." 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.
Next steps
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 and other healthcare workers can quickly and efficiently prioritize important findings and effectively communicate them to referring providers, while providing receipt of the critical communications.
In promoting improved systems of medical communication, radiologists and other medical professionals protect themselves, their hospitals, and ultimately the health and safety of the patients they serve.
Richard M. Chesbrough, MD, is founder of RADAR Medical Systems. He can be reached at rchesbrough@radarmed.com.
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