Effective communication is a critical component of diagnostic imaging. Although each clinical scenario may have varying factors that influence the method of communication between providers, timely receipt of imaging reports is more important than the delivery mode. When healthcare facilities fail to implement and follow an effective system for communication, the consequences can lead to negative and many times avoidable outcomes.
In this study, we examine how a failure to communicate abnormal test results resulted in the death of a patient. We’ll also provide strategies for appropriate and timely communication of diagnostic imaging findings.
A 63-year-old patient presented to the ED in 2002 with complaints of nausea, vomiting, diarrhea, and fever. He previously smoked two packs of cigarettes each day for roughly 30 years but had quit 15 years prior.
The ED’s Advanced Practice Provider (APP) ordered an acute abdominal series imaging study with three views of the abdomen and a PA view of the chest. The APP interpreted the x-rays as normal and discharged the patient at 6:15 p.m. with a diagnosis of viral gastroenteritis and hypokalemia. However, the APP did not send a preliminary report of his findings to the radiologist.
The radiologist interpreting the films noted an ill-defined density in the left lung, stating that it may represent a focal infiltrate but that further evaluation is necessary. The radiologist also recorded a concern for neoplasm and recommended a CT examination with contrast, requesting that the document be faxed to a treating physician. This report was filed into the medical record, but the ED physician stated that he never received the results, and the radiologist did not call the physician directly.
Following this encounter, the patient had multiple procedures and diagnostic studies performed without any indication of a mass. He presented to his primary care physician three years later with an acute episode of diaphoresis, cough, and congestion. The PCP ordered a chest x-ray and noted the results from the 2002 study. The patient was then referred to a cardio-thoracic surgeon for consultation and treatment.
The mass was reported as stage III non-small cell carcinoma without metastasis. The cardio-thoracic surgeon determined that the tumor was inoperable, and the patient underwent a course of radiation and chemotherapy. Due to aggressive treatment, the tumor decreased in size, and the patient’s condition remained stable for some time.
In 2007, studies showed evidence of a new tumor in the patient’s right lung. At that time, it was unknown if this was a new primary tumor or metastasis from the previous tumor in the left lung. During work-up, it was determined the cancer had already spread to his brain. The patient underwent aggressive chemotherapy and radiation, yet his condition continued to deteriorate until his death in 2010.
What Went Wrong?
Though the radiologist correctly interpreted the image, and the final report was faxed to the referring physician, there was a failure to notify the patient of abnormal test findings that resulted in delayed treatment and ultimately death.
In addition, the APP read the results as normal, and the preliminary read was not provided to the radiologist for review. Furthermore, the hospital did not have a policy in place to address test results reported after patient discharge, and the ED did not have a tracking process to ensure the appropriate provider received results for all tests ordered.
Given these facts, the claim was settled before trial. However, had the radiologist called the findings to the ED and documented this activity, he would have likely increased his chance of being dismissed from the claim.
Risk Management Takeaways
- Hospitals and practices should require written preliminary reports when accepting new patients, and radiologists should directly contact the referring provider to request reports in cases where they have not received this information.
- Hospitals and practices should develop a written communication policy for referring patients and reporting test findings that:
- Defines the role and responsibilities of the referring provider and radiologist on reporting preliminary and final report findings
- Outlines the method of delivery for critical findings
- Provides guidelines for faxing the radiology findings to the referring provider
- States any recommended additional studies be included in the final report and communicated to the referring provider
- Outlines documentation requirements, including who received the report
For further guidance on this issue, Curi members are encouraged to reach out to our Claims and Risk Management Departments at 800.662.7917.
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