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What’s New in the Patient Safety World

February 2022


·       Communication Failures and Malpractice

·       TIA Clinics Provide Safe Patient Care

·       Does Time of Day Matter?

·       Managing Incidental Findings




Communication Failures and Malpractice



It should come as no surprise that communication issues are a major contributor to malpractice claims, since communication issues are contributing factors in the majority of our root cause analyses into serious adverse events. But there has been little actual data published on the role of miscommunication in malpractice claims.


In a new study researchers reviewed a random sample of malpractice claims from 2001 to 2011, collected in CRICO Strategies’ Comparative Benchmarking System, a national claims database (Humphrey 2021). They identified communication failures in 49% of claims. Moreover, claims with communication failures were significantly less likely to be dropped, denied, or dismissed than claims without (54% versus 67%, P = 0.015) and total costs were higher for those claims with communication failures. Of those claims with communication failures 53% involved provider-patient miscommunication and 47% involved provider-provider miscommunication. Communication errors among medical staff most often occurred between the attending physician and the nursing staff (37%), attending physicians between specialties (30%) and within a specialty (19%). Specific information types most frequently identified were contingency plans, diagnosis, and illness severity. The researchers found that 40% of communication failures involved a failed handoff and that 77% could potentially have been averted by using a handoff tool.


The focus on handoffs is also not surprising, since the senior author of the study was Chris Landrigan, M.D., M.P.H., Co-Founder of the I-PASS Patient Safety Institute, whose work we have highlighted in our many columns on handoff issues (listed below). Handoffs occur between multiple types of healthcare providers and always represent potential opportunities for error. Handoffs should be done using structured formats, such as I-PASS or one of the other tools highlighted in the columns below. But equally important, handoffs should be conducted in a venue in which interruptions and distractions are minimized, ample time is allotted, and the receipient of the handoff is an active participant, asking questions and acknowledging important points.



Read about many other handoff issues (in both healthcare and other industries) in some of our previous columns:


May 15, 2007              Communication, Hearback and Other Lessons from Aviation

May 22, 2007              More on TeamSTEPPS

August 28, 2007         Lessons Learned from Transportation Accidents

December 11, 2007     Communication…Communication…Communication

February 26, 2008       Nightmares….The Hospital at Night

September 30, 2008     Hot Topic: Handoffs

November 18, 2008     Ticket to Ride: Checklist, Form, or Decision Scorecard?

December 2008            Another Good Paper on Handoffs”.

June 30, 2009               iSoBAR: Australian Clinical Handoffs/Handovers

April 25, 2009             Interruptions, Distractions, Inattention…Oops!

April 13, 2010             Update on Handoffs

July 12, 2011              Psst! Pass it on…How a kid’s game can mold good handoffs

July 19, 2011              Communication Across Professions

November 2011           Restricted Housestaff Work Hours and Patient Handoffs

December 2011            AORN Perioperative Handoff Toolkit

February 14, 2012       Handoffs – More Than Battle of the Mnemonics

March 2012                 More on Perioperative Handoffs

June 2012                    I-PASS Results and Resources Now Available

August 2012               New Joint Commission Tools for Improving Handoffs

August 2012                Review of Postoperative Handoffs

January 29, 2013         A Flurry of Activity on Handoffs

December 10, 2013     Better Handoffs, Better Results

February 11, 2014       Another Perioperative Handoff Tool: SWITCH

March 2014                  The “Reverse” Perioperative Handoff: ICU to OR

September 9, 2014      The Handback

December 2014            I-PASS Passes the Test

January 6, 2015            Yet Another Handoff: The Intraoperative Handoff

March 2017                 Adding Structure to Multidisciplinary Rounds

August 22, 2017         OR to ICU Handoff Success

October 2017              Joint Commission Sentinel Event Alert on Handoffs

October 30, 2018        Interhospital Transfers

April 9, 2019               Handoffs for Every Occasion

November 2019          I-PASS Delivers Again

August 2020               New Twist on Resident Work Hours and Patient Safety

September 29, 2020    ISHAPED for Nursing Handoffs

May 25, 2021              Yes, Radiologists Have Handoffs, Too






Humphrey KE, Sundberg M, Milliren CE, et al. Frequency and Nature of Communication and Handoff Failures in Medical Malpractice Claims. Journal of Patient Safety 2021; December 15, 2021 - Volume - Issue -



I-PASS Patient Safety Institute






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TIA Clinics Provide Safe Patient Care



Speed is of the utmost importance when dealing with patients having a stroke. But it is also of importance in patients having a TIA (transient ischemic attack). The risk of stroke is especially high within the first 48 hours following a TIA. Hence, prompt evaluation and implementation of measures to prevent stroke is essential when confronted with a patient having a TIA.


Of patients presenting to an emergency department with TIA, 5.3% had a stroke during the first 2 days, and 10.5% within 90 days of TIA presentation (Johnston 2000). Another study (Lovett 2003) found that, of patients with a first-ever TIA, the risk of stroke was 8.6% at 7 days and 12.0% at 30 days


A systematic review and meta-analysis showed the rate of subsequent ischemic stroke after TIA was estimated to be 2.4% within 2 days, 3.8% within 7 days, 4.1% within 30 days, and 4.7% within 90 days (Shahjouei 2021).


The Framingham Heart Study showed that after TIA, 21.5% of strokes occurred within 7 days, 30.8% within 30 days, 39.2% within 90 days, and 48.5% more than 1 year after the index TIA (Lioutas 2021).


Studies have shown up to an 80% reduction in the risk of stroke after a TIA with early implementation of secondary stroke prevention strategies (Shahjouei 2022). Therefore, it is incumbent upon us to get the evaluation of the TIA patient completed as soon as possible following the TIA. In the past, most such evaluations were done in the emergency department or hospital. But in recent years we have had a push to get that evaluation done promptly on an outpatient basis in “TIA clinics”.


There has always been some concern about doing that evaluation as an outpatient. So, recently, Shahjouei and colleagues (Shahjouei 2022) did a systematic review and meta-analysis of studies on the risk of subsequent stroke among patients receiving outpatient vs inpatient care for TIA.


Among the patients who were treated at a TIA clinic, the risk of subsequent stroke following a TIA or minor ischemic stroke was 0.3% within 2 days, 1.0% within 7 days, 1.3% within 30 days, and 2.1% within 90 days. Among the patients who were treated as inpatients, the risk of subsequent stroke was to 0.5% within 2 days, 1.2% within 7 days, 1.6% within 30 days, and 2.8% (95% CI, 2.1%-3.5%) within 90 days. For those seen in the ED’s, the risk was 1.9% within 2 days, 3.4% within 7 days, 3.5% within 30 days, and 3.5% within 90 days. The risk of stroke among patients treated at TIA clinics was not significantly different from those hospitalized.


The authors conclude that the risk of subsequent stroke among patients who were evaluated in a TIA clinic was not higher than those hospitalized. Patients who received treatment in ED’s without further follow-up had a higher risk of subsequent stroke. These findings suggest that TIA clinics can be an effective component of the TIA care component pathway.


Note, however, that patients seen in TIA clinics tended to be younger and had lower ABCD2 scores. Many guidelines suggest that higher risk patients with TIA, such as those with higher ABCD2 scores, be evaluated as inpatients.


The authors also note that many patients seen in the ED may not have formal neurological consulations. They note that the percentage of TIA misdiagnosis can be as high as 60% in ED’s and primary care offices. They also note that “TIA mimics” (eg. migraine aura) may be misdiagnosed as TIA’s in such patients.


Overall, the Shahjouei meta-analysis is reassuring that the outcomes of TIA patients evaluated at TIA clinics are at least as good as those of hospitalized TIA patients, and may be even better than those of patients evaluated in the ED without designated followup. But any TIA clinic must be staffed by neurologists (or other provider with equivalent neurological training) and have ready access to ultrasound, imaging, and cardiac tools. And followup is essesntial for appropriate management of stroke risk factors, and compliance with more recent recommendations for antiplatelet therapy.






Johnston SC, Gress DR, Browner WS, Sidney S. Short-term prognosis after emergency department diagnosis of TIA. JAMA 2000; 284: 2901-2906



Lovett JK, Dennis MS, Sandercock PAG, et al. Very Early Risk of Stroke After a First Transient Ischemic Attack. Stroke 2003; 34: e138-e140



Shahjouei S, Sadighi A, Chaudhary D, et al. A 5-Decade Analysis of Incidence Trends of Ischemic Stroke After Transient Ischemic Attack: A Systematic Review and Meta-analysis. JAMA Neurol 2021; 78(1): 77=87



Lioutas V, Ivan CS, Himali JJ, et al. Incidence of Transient Ischemic Attack and Association With Long-term Risk of Stroke. JAMA 2021; 325(4): 373-381



Shahjouei S, Li J, Koza E, et al. Risk of Subsequent Stroke Among Patients Receiving Outpatient vs Inpatient Care for Transient Ischemic Attack: A Systematic Review and Meta-analysis. JAMA Netw Open 2022; 5(1): e2136644





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Does Time of Day Matter?



We’ve done multiple columns on “the weekend effect” and “the after hours effect”, in which patient outcomes tend to be worse than for those during “normal” daytime hours. But beyond time of day or day of the week, there is variation in performance by time during a working shift.


In our May 3, 2011 Patient Safety Tip of the Week “It’s All in the Timing” we noted that detection rates for polyps or adenomas during colonoscopy fell off during colonoscopies done later in a shift. And in our June 2019 What's New in the Patient Safety World column “More on the Time of Day” we noted your chance of getting an influenza vaccination or one of several preventive screening procedures also falls off when you are seen late in the day.


The phenomenon is seen in radiologists, too. In our August 25, 2020 Patient Safety Tip of the Week “The Off-Hours Effect in Radiology” we noted a study which looked at the performance of radiology fellows who have completed full radiology residencies (all of whom successfully completed the American Board of Radiology board certification following their fellowship year), comparing CT scan reading error rates during daytime or night shifts (Patel 2020). Nighttime studies had error rates of 3%, compared to 2% for daytime studies, and 69% of the radiology fellows had higher error rates for night cases. But, while the focus of the study was on nighttime vs. daytime error rates, there were significantly more errors during the last half of night assignments (3.7%) compared with the first half (2.5%). Diagnostic error rates were also lower in the first half of the day assignment from 7:00 AM to 11:59 AM compared with the second half from 12:00 PM to 5:59 PM (1.1% vs. 2.6%), but that difference was not statistically significant.


A new study (Bernstein 2022) showed that patients were more likely to be recalled when their screening digital breast tomosynthesis images were interpreted later in the day by less-experienced radiologists. Thr researchers looked at recall and false-positive (FP) rates in radiologists’ interpretation of digital breast tomosynthesis (DBT) images digital mammography (DM) images (the authors note that digital breast tomosynthesis image interpretation might be more cognitively demanding than interpretation of digital mammography images). But they also looked at the impact of time of day on these rates.


Overall, for every additional hour of reading time, the odds of recall increased by 6.6% for DBT, a sharper increase than that for DM. Similarly, for every additional hour in reading time, the odds of an falso positive finding increased by 6.8%, whereas the increase for DM was 3.9%. For every additional hour in reading time, the odds of a true positive finding increased by 3.4% for DBT and by 2.2% for DM. But results were significantly impacted by experience of the radiologist. For radiologists with 5 or fewer posttraining years of experience, odds of recall increased 11.5% with every hour when using DBT, but this was not found for DM. For radiologists with more than 5 posttraining years of experience, no evidence of increase in recall was observed for DBT or DM.


Physicians, nurses, and really all healthcare workers tend to have drop-offs in performance when fatigued. There are, of course, multiple studies demonstrating the impact of fatigue on on radiologists. Krupinski et al. (Krupinski 2010) found that, after a day of clinical reading, radiologists have reduced ability to focus, increased symptoms of fatigue and oculomotor strain, and reduced ability to detect fractures. In our April 2018 What's New in the Patient Safety World column “Radiologists Get Fatigued, Too” we highlighted a study looking at the effect of overnight shifts on performance of radiologists (Hanna 2018). The researchers used a tool for measuring fatigue and advance eye tracking technology to assess the performance of radiologists (both attendings and residents). Not surprisingly, participants demonstrated worse diagnostic performance in the fatigued versus not-fatigued state. Viewing time per case was significantly prolonged when the radiologists were fatigued. Mean total fixations generated during the search increased by 60% during fatigued sessions. Mean time to first fixate on bone fractures increased by 34% during fatigued sessions. Moreover, dwell times associated with true- and false-positive decisions increased, whereas those with false negatives decreased. Effects of fatigue were more pronounced in residents, in keeping with the findings of Bernstein et al. regarding the impact of experience.


Hanna et al. concluded that further research is needed to address and reverse the impact of such fatigue-related changes. They speculate that environmental changes (eg. lighting) and activity changes (eg. periodic breaks, moving around, etc.) might help mitigate the adverse effects of fatigue on performance.



Some of our other columns on the impact of time of day on patient outcomes:


May 3, 2011 “It’s All in the Timing

June 2019 “More on the Time of Day

August 25, 2020 “The Off-Hours Effect in Radiology



Some of our other columns on the role of fatigue in Patient Safety:


November 9, 2010      12-Hour Nursing Shifts and Patient Safety

April 26, 2011             Sleeping Air Traffic Controllers: What About Healthcare?

February 2011             Update on 12-hour Nursing Shifts

September 2011          Shiftwork and Patient Safety

November 2011          Restricted Housestaff Work Hours and Patient Handoffs

January 2012               Joint Commission Sentinel Event Alert: Healthcare Worker Fatigue and Patient Safety

January 3, 2012           Unintended Consequences of Restricted Housestaff Hours

June 2012                    June 2012 Surgeon Fatigue

November 2012          The Mid-Day Nap

November 13, 2012    The 12-Hour Nursing Shift: More Downsides

July 29, 2014              The 12-Hour Nursing Shift: Debate Continues

October 2014              Another Rap on the 12-Hour Nursing Shift

December 2, 2014       ANA Position Statement on Nurse Fatigue

August 2015               Surgical Resident Duty Reform and Postoperative Outcomes

September 2015          Surgery Previous Night Does Not Impact Attending Surgeon Next Day

September 29, 2015    More on the 12-Hour Nursing Shift

September 6, 2016      Napping Debate Rekindled

April 18, 2017             Alarm Response and Nurse Shift Duration

July 11, 2017              The 12-Hour Shift Takes More Hits

February 13, 2018       Interruptions in the ED

April 2018                   Radiologists Get Fatigued, Too

August 2018               Burnout and Medical Errors

September 4, 2018      The 12-Hour Nursing Shift: Another Nail in the Coffin

August 2020               New Twist on Resident Work Hours and Patient Safety

August 25, 2020         The Off-Hours Effect in Radiology

September 2020          Daylight Savings Time Impacts Patient Safety?

January 19, 2021         Technology to Identify Fatigue?

October 12, 2021        FDA Approval of Concussion Tool – Why Not a Fatigue Detection Tool?






Patel AG, Pizzitola VJ, Johnson CD, et al. Radiologists Make More Errors Interpreting Off-Hours Body CT Studies during Overnight Assignments as Compared with Daytime Assignments. Radiology 2020; 297(2): 374-379 Published Online: Aug 18 2020



Bernstein MH, Baird GL, Lourenco AP. Digital Breast Tomosynthesis and Digital Mammography Recall and False-Positive Rates by Time of Day and Reader Experience

Radiology 2022; Publlished online January 11, 2022



Krupinski EA, Berbaum KS, Caldwell RT, Schartz KM, Kim J. Long radiology workdays reduce detection and accommodation accuracy. JAm Coll Radiol 2010; 7(9): 698-704



Hanna TN, Zygmont ME, Peterson R, et al. The effects of fatigue from overnight

shifts on radiology search patterns and diagnostic performance. J Am Coll Radiol 2018; 15(12): 1709-1716








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Managing Incidental Findings



Incidental findings on imaging studies may be benign and have no impact on patients. But they may also be important signs of serious conditions, such as cancer. Hence, it is important that incidental findings be managed appropriately. “Closing the loop” and communicating about incidental findings is critical to ensure patients do not “fall through the cracks”. Keep in mind that almost everything we say about incidental findings on imaging studies may also apply to incidental findings on other diagnostic studies, like lab and pathology studies.


Our April 13, 2021 Patient Safety Tip of the Week “Incidental Findings – What’s Your Strategy?” outlined many strategies for managing incidental findings. We stressed that the most appropriate followup actions depend on the specific nature of the incidental finding. There are numerous guidelines regarding what to do for specific incidental findings. But there are 2 key issues:


Since that column we came across an excellent article on managing incidental findings (Makeeva 2021). Makeeva et al. note that approx­imately 65% of all incidental findings are “actionable” and that, among these, a diagnosis is confirmed in approximately 45% of patients. They also note the incidence of cancer among all incidental findings com­pleting follow-up is 2.3-4.5%.


As we have pointed out, many medical societies and the American College of Radiology have published guidelines on how to approach various incidental findings. Makeela et al. point out that evidence-based documents guide radiologists in identifying findings that do or do not require follow-up and can help radiologists issue follow-up recommendations with regards to imaging modality and fol­low-up time intervals. Importantly, they note that evidence-based guidance can prevent unnecessary follow-up tests, thereby decreasing patient anxiety and financial burden on patients and society. Bt, unfortunately, there is not always a strong evidence base to provide guidance for some incidental findings.


How you communicate the findings and recommendations is important. Makeela et al. note that follow-up recommendation lan­guage should be clear and concise. They should not be so vague as to prevent the ordering clinician from understanding the necessity of follow-up.  For example, they note that statements like, “If clinically indicat­ed, follow-up CT could be performed in 4–6 weeks to document resolution,” limit clinicians’ ability to judge the necessity of follow-up and lead to low follow-up rates. Instead, they note that recommendations which  pre­cisely identify the lesion in question, the recommended modality, and time interval can result in higher completion rates. They recommend those detailed recom­mendations should be placed in the “Impression” section of the radiology report, where they can be easily seen and noted by clinicians. Links to the references for specific evidence-based guidelines can be included in the reports. Many radiologists have access to templates that can be used for specific incidental findings.


They also stress the importance of patient engagement in ensuring adequate follow-up.They note that in some venues, such as emergency departments and some radiology sites, the radiologist can speak directly to the patient. Ensuring patients fully understand the findings and their next steps. They also note that patients now have potential access to all their medical records, including reports of imaging studies. But the language in those reports may be too technical for patients to fully understand. But they note that “placing Info-RADS messag­es in radiology reports is an effective way to convey the nature of imaging results and whether any further steps are necessary. These messages indi­cate to patients either that the results are normal and no additional steps need to be taken, or that there was a non-emergent finding for which the patient should contact their provid­er to discuss next steps.”


They then discuss in detail our second key issue - having a system in place to find out that appropriate follow up, indeed, occurred. They note that tracking systems can considerably improve the chances that appropriate follow-up took place.


Hybrid tracking systems, using both staff and IT resources, may be effective. Including key words for phrases in imaging reports can flag those cases in which the tracking system should be activated.  One example they provide is including the text “#follow” in the report. Newer tracking systems are also using natural language processing (NLP) capabilities to identify cases needing tracking.


They go on to describe what a fully automated tracking system would be able to do:


Of course, inadequate interoperability still presents challenges to any tracking system. We often see patients who get all their subsequent care in offices or health systems that do not communicate with the IT systems of the imaging department or practice. Sometimes, the patient is not even in the same geographic region after the initial imaging study. In our mind, that really increases the importance of that direct communication with the patient at the time of the study.


Overall, the Makeela paper has good recommendations. It is also well-referenced and has a couple nice workflow diagrams. We also refer you back to our many prior columns on communicating significant results and especially our April 13, 2021 Patient Safety Tip of the Week “Incidental Findings – What’s Your Strategy?”.



See also our other columns on communicating significant results:






Makeeva V, Schofield K, Davis M, Kadom N. Managing Incidental Findings. Appl Radiol. 2021; 50(6): 22-26





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