Communicating Radiology Results

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Communicating Radiology Results

• Jonathan Kruskal, MD, PhD
• Director, Radiology QA

QA Rounds 6
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Assumptions

• Ordering docs ordered the study
• Ordering docs get our reports
• Ordering docs read our reports
• Ordering docs act on our reports
• Making a recommendation doesnt close the loop
  if you see it, you own it

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Ordering docs order the study

• NOT! Dont assume they are looking for the result
• Consulting service report doesnt get to PCP
• Procedure services order routine studies
• Pre-op chest radiographs
• Cardiologists order atrial imaging
• Covering PCP or PA (Joslin or ED) can order
• Patients admitted from the ED to different
  service are a big problem for us
• Who owns the study? Order it own it!

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Ordering Docs Receive Our Reports

• Not always!
• Some get faxed..where? No recording or tracking
  system
• E-mails are not reliable assistants may read
• Many are ordered by outside physicians not using
  Careweb
• We are forced to use the Mass BoRM website
• Dont assume reports are read

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Ordering Docs Act on Our Reports

• Not always potential serious medicolegal
  consequences for them, and for us
• We have no means for knowing what recommendations
  are followed up we only hear of the disasters
• Do we need a tracking system like mammo?
• Lung nodule recommend chest CT
• Vague shadow recommend chest CT

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Ordering Docs Read Our Reports

• Not always
• We dont always prioritize information
• Think about the conclusion Maestro Ferris Hall
• Often dont read after receiving wet read
• Reported as near misses
• Dont assume reports are read after giving verbal
  preliminary read

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QA Project Opportunities

• Who are ordering studies?
• Where are our reports going?
• Who is reading the reports?
• What are they doing with important information?
• How are recommendations for follow up being
  followed?

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Our Communication Policy

• Defined list of critical results
• Require documented communication
• We are not always complying with this policy
• To monitor compliance
• Requested feedback from clinical services
• Analysis of addended reports
• Wordsearch of critical indicators

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Monitoring Compliance

• Each section has an indicator
• We are expected to monitor this monthly
• Great resident elective opportunity
• I beg your support compliance
• Compliance is up to each Section Chief

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Monitoring Compliance

• chest new lung nodule on chest CT
• OB ultrasound ectopic pregnancy
• neuro acute parenchymal bleed
• MSK new fracture
• IR major complication
• mammo biopsy recommendation
• abdomen pretransplant liver mass
• ED spine fracture
• nuclear medicine high likelihood lung scans
• ED wet read compliance

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Communicating Complications

• All complications must be communicated and this
  communication must be documented.
• Are we ready to apologize to patients?
• Patient disclosures are now expected for all
  cases discussed at QI Directors group so we
  should start doing this as a routine.

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Communicating Misses

• How do we do this?
• How should we do this?
• Should we do this?

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What We Currently Do

• Data only from Body Section since none other
  available, currently
• For 18 months of abdominal CT scan misses,
  defined as those impacting on care, staging, or
  management

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148 Misses

• 39 (26.7) directly communicated
• 30 of which didnt addend report
• 9 (6.2) original reports addended
• No mention of miss or error
• 23 (12.2) only mentioned change
• 3 (1.9) stated miss or error
• 109 (73.6) NOT communicated

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According to Len Berlin..

• No ethical or professional society-sanctioned
  requirements that omissions be voluntarily
  reported
• ACR (as well as compelling ethical legal
  considerations) favors complete disclosure of all
  errors
• No legal duty to disclose errors or misses

Reporting the Missed Radiologic Diagnosis
Radiology 1994 192 183-7
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So what should we do?

• A simple statement such as in retrospect, the
  lesion was present on the prior radiograph is
  sufficient.
• Words such as missed, error or mistake or
  phrases such as should have been seen or was
  present but not seem should be avoided.

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Some suggestions.

• Never ever compromise patient care
• Dont make assumptions about care
• Dont make assumptions
• Never compromise care that another physician is
  trying to provide
• Dont second guess or make clinical decisions for
  other physicians patients

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What next? In the ideal setting

• Tracking system for all recommendations or
  follow-ups
• Auto system for communicating critical or other
  important results
• System for monitoring compliance with
  communication
• Many resident elective opportunities

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In summary.

• Ordering docs dont always order the study
• Ordering docs dont always get our reports
• Ordering docs dont always read our reports
• Ordering docs dont always act on our reports
• Making a recommendation doesnt close the loop
  if you see it, you own it