Communication of urgent or unexpected radiology findings is an issue we have discussed on numerous occasions. One of our continuing hot buttons is results of significant clinical findings slipping through the cracks. We discussed these extensively in our Patient Safety Tips of the Week for May 1, 2007 “The Missed Cancer”, February 12, 2008 “More on Tracking Test Results”, October 13, 2009 “Slipping Through the Cracks”, and our July 2009 What’s New in the Patient Safety World “Failure to Inform Patients of Clinically Significant Outpatient Test Results”. It continues to be an area of concern, as evidenced by several recent published articles.
Our recommendation has always been that there should be two systems in place: one in the radiology department to ensure the message gets to the person who needs to know and one with the ordering physician that ensures the physician always identifies results of tests ordered. We’ve talked about 2 types of system: paper and electronic. And some findings would require both. Actually, there should be a 3rd system in place as well: one with the patients themselves. The educated patient should always ask the provider “when should I expect the result to be available?” and then contact the provider if they have not heard those results within a reasonable period of time.
Here are some pretty scary statistics (): failure to communicate radiologic findings to referring physicians is a factor in 80% of malpractice suits for radiologists (in 60% the findings were never directly communicated to the referring physician) and the average payment to plaintiffs is $1.9 million per case. And the courts have increasingly been taking the position that the radiologist is responsible to ensure that those test results are acknowledged by the referring physician.
The ACR (American College of Radiology) does have Lucey 2010). They include recommendations for communication of both routine findings, preliminary reports, final reports, and discrepancies. The Royal College of Radiologists (UK) also has issued standards for the communication of critical, urgent and unexpected significant radiological findings. These include some recommendations from a National Patient Safety Agency Safer Practice Notice “Early identification of failure to act on radiological imaging reports” (2007). These guidelines also include recommendations for keeping patients informed (eg. how to expect to get their results, etc.). They do recommend also communicating results to people other than the ordering/referring physician (eg. also send results to the primary care physician, multispecialty cancer teams, etc.). But please see our October 13, 2009 Patient Safety Tip of the Week “Slipping Through the Cracks” in which we cite a paper by Singh et al 2009 that demonstrated dual alerts (those sent to both the referring physician and the primary care physician) were twice as likely to go unacknowledged.. These were last revised in 2005 and may be revised again later this year (
The Royal College of Radiologists (UK) also has audit tools available to help organizations assess their performance in such communications.
The ordering physician also has obligations. The ability to track referrals and tests is a requirement for Patient-Centered Medical Home (PCMH) certification. This is especially important given a recent paper (Weiner et al 2010) that demonstrated only 50% of referrals actually resulted in elderly patients being seen by a specialist consultant. Though that study did not look at radiology referrals, one wonders what the comparable rate is for completed radiology tests in that population. And though that paper did not capture the specific reasons for failure to have the consultation scheduled or kept, they did discuss the numerous system and communication aspects that might be contributory.
For both testing and consultations, MLMIC (a malpractice carrier in NYS) recommends the following be done by the primary care or ordering physician:
1. Educate patients about the need for the testing, and document this conversation.
2. Implement a follow-up system in your practice to ensure that patients have undergone the recommended testing and that the results are returned to the office.
3. The follow-up system should include the patient’s name, the date the test was ordered, when the results were received, and when the patient was notified.
4. The physician should review, initial, and date the reports before they are filed in the medical record.
5. Attempts should be made to contact patients who have not undergone the recommended testing. These attempts should be documented in the medical record and, once the patient has been reached, he/she should again be urged to obtain the requested testing.
6. Include a process in your follow-up system to verify that consultations were obtained.
We’d again like to stress that any provider who orders tests must have some sort of system, paper or electronic, to remind them to check on results of all tests they have ordered. Remember, the system must also alert the provider to those cases where the test was never done! Failure to have the test done may be just as significant an issue. So your “tickler” system must say something like “if I haven’t heard Mrs. Smith’s CT scan result by Friday, I need to find out why not”. And the patient, as above, should always ask the provider “When should I expect the result to be available?” and then contact the provider if they have not heard those results within a reasonable period of time. The patient should never assume that the test results were normal if they have not heard from the physician or other provider.
But there are two other key circumstances where the ordering physician may never again see the patient:
1. The patient followed by a hospitalist as an inpatient (or similar inpatient coverage)
2. The patient seen by an emergency department physician
These are circumstances especially vulnerable to lack of followup of abnormal test results. In many ER’s there are either no real-time readings of radiology studies by radiologists or the readings are preliminary “wet reads” that are followed up with an official report later. By the time the official report is done, both the patient and the ER physician are usually long gone.
The March 2010 issue of the Pennsylvania Patient Safety Advisory has an article on communication of radiograph discrepancies between radiology and emergency departments. The Pennsylvania Patient Safety Authority had received over 3000 reports of ER radiology discrepancies over a 4 year period. While the vast majority were of no clinical significance, there were discrepancies that did affect patient care (eg. fractures, pneumonia, appendicitis). The article contains some good risk reduction strategies. They recommend a system be in place to review discrepancies between the ER physician interpretation and the radiologist interpretation for all shifts. The system can be either paper-based or use notations on the PACS system. But the key thing is that it is a two-way system. The radiologist needs to see how the ER physician interpreted the study and vice versa. Discrepancies must be communicated to the ER in a timely fashion. The method of communication is most often verbal between practitioners and such communication should be documented in the patient’s medical record. And then a system must be in place for timely communication of the discrepancies and findings to the referring physician or physician who will be assuming care of the patient or the patient himself. There has been an increasing trend for radiologists to communicate directly with patients regarding the findings.
For patients discharged from the hospital inpatient units, it is not uncommon to have some radiology studies for which the final “official” report has not yet reached the chart. We have long advocated that discharge summaries contain a specific section for “pending test results” so that it is appropriately conveyed to whomever will be providing care subsequent to discharge that they need to check on those test results. But a recent study (Were et al 2009) showed that only 16% of tests with results pending actually are documented in discharge summaries (for those of you not having access to the Journal of General Internal Medicine, the article is also summarized by Gesensway in Today’s Hospitalist in January 2010). Only 25% of the discharge summaries mention any pending tests results and only 13% mention what those pending tests are. Dr. Were points out that most hospitalists don’t even have a full list of what tests are pending because today’s EMR’s are not yet sophisticated enough or integrated enough to compile such lists (and someone other than the hospitalist may have ordered those tests sometime during the hospital stay). So the hospitalist him/herself is really responsible for the time being to followup on all test results. Confound that with hospitalists working shifts and taking vacations and it is easy to see how test results can fall through the cracks. Some systems will use other healthcare personnel to help bridge continuity in such cases (eg. a nurse case manager or someone working for the hospitalist group might be responsible for collecting all test results when the hospitalist leaves).
Yee KM. Communication failure: A surefire route to
AuntMinnie.com. February 16, 2010
American College of Radiology (ACR). Practice Guideline For Communication Of Diagnostic Imaging Findings. Revised 2005
Lucey LL, Kushner DC. The ACR Guideline on Communication: To Be or Not to Be, That Is the Question. Journal of the Americal College of Radiology 2010; 7(2): 109-114
The Royal College of Radiologists (UK). Standards for the communication of critical, urgent and unexpected significant radiological findings. 2008
NPSA (UK). Safer Practice Notice 16. Early identification of failure to act on radiological imaging reports. 5 February 2007
Singh H, Thomas EJ, Mani S, et al. Timely Follow-up of Abnormal Diagnostic Imaging Test Results in an Outpatient Setting. Arch Intern Med. 2009; 169(17): 1578-1586.
The Royal College of Radiologists. Audit tools.
The Royal College of Radiologists. Template for audit on communication of urgent findings.
Weiner M, Perkins AJ, Callahan CM. Errors in completion of referrals among older urban adults in ambulatory care. Journal of Evaluation in Clinical Practice 2010; 16: 76-81
MLMIC tips on tracking test results
PPSA Communication of Radiograph Discrepancies between Radiology and Emergency Departments
Pa Patient Saf Advis 2010; 7(1): 18-22
Were MC, Li X, Kesterson J, et al. Adequacy of Hospital Discharge Summaries in Documenting Tests with Pending Results and Outpatient Follow-up Providers. Journal of General Internal Medicine 2009; 24(9): 1002-1006
Gesensway D. Pending test results go AWOL. Physicians mention only 16% of pending tests in discharge summaries. Today's Hospitalist 2010 (January 2010 issue)
See also our other columns on communicating significant results: