We’ve done numerous columns on errors in communicating radiology results to physicians and patients (see the full list at the end of today’s column). A new study demonstrates frequent communication errors related to radiology (Siewert 2016). But the surprising finding was that the majority of those communication errors occurred at steps other than communication of test results! Results communication was still the single most common communication error but errors during ordering, scheduling, performance, and interpretation of a study were collectively more frequent.
The breakdown of communication errors was:
Mistakes could occur in written or verbal or electronic communication. Communication errors could occur between the radiologist and the ordering/referring physician or between the radiologist and the radiology technician.
In 37.9% of cases there was an impact on patient care, including major impacts (such as delayed recognition of malignancies or other serious conditions) in 23.4%. The authors also note that there was potential for patient impact in the majority of cases in which no actual impact was noted.
Communication errors also impact efficiency, leading to re-work in many cases, and patient inconvenience when studies need to be delayed or repeated. Communication errors may also lead to dissatisfaction on the parts of referring physicians and patients.
A recent review of radiology malpractice claims found such claims most commonly involve diagnosis-related allegations in the outpatient setting, particularly cancer diagnoses (Harvey 2016). But of interest in that study is that only 1.3% of claims involved communication failures as the primary allegation (plus an additional 4.6% as contributory factors in diagnostic-related allegations). That suggests that radiology practices are improving with respect to communication of significant test results.
Harvey and colleagues, however, do note another aspect of communication that may be a factor in malpractice claims. While they note that the preponderance of claims related to ambulatory settings may simply reflect the higher frequency of imaging in that setting, they also point out that the lack of IT integration may render the ambulatory setting more vulnerable than the inpatient setting. They note many studies have demonstrated that insufficient clinical data available to the radiologist increases the likelihood of a diagnostic “miss”. Whereas the institutional medical record may provide important collateral clinical information for the radiologist for inpatient cases, such data is often not available for many outpatients.
We empathize with radiologists who have suboptimal clinical information when interpreting imaging studies. In the era before electronic medical records that lack of clinical information was even more prevalent. We’d come across requisitions for abdominal imaging that simply gave “pneumonia” as the reason for referral. Many of the requisitions were, in fact, filled out by ward clerical staff after the physician wrote an order for the imaging study. Often the radiology technician or radiologist would have to ask the patient if they knew what the physicians were looking for and they often did not know or, worse yet, gave misleading reasons. A good radiologist would try to contact the ordering physician but that was not always practical or successful in a compressed timeframe. Today hospital radiologists usually have access to the electronic medical record if the patient is an inpatient or in a system where system-wide records are available. But many outpatient radiology practices have no such access to clinical information other than what was provided in the requisition.
We recommend you review a representative sample of your radiology requisitions. Pay particular attention to those requisitions that are transmitted through physician order entry systems. Many of those use drop-down lists or checkboxes in the field for “reason for study”. While such may promote ease of entry, they often lack sufficient detail for the interpreting radiologist that might be better served by additional free text information. Whether your requisition system is an electronic one or paper-based you may find you need to retool it to provide better communication from the referring physician to the radiologist. A good system also can improve efficiency (for example, might reduce the number of phone calls a scheduler or radiology tech has to make to clarify things like use of contrast, etc.). Good systems with clinical decision support tools also may help direct the ordering physician to the most appropriate study and avoid unnecessary imaging studies.
Good communication between the referring physician’s office and the radiology practice scheduling personnel can minimize the number of issues that arise. But the radiology staff are often distracted over details such as insurance coverage, etc. and may be less concerned about getting the necessary clinical information. Ironically, many of the “dreaded” third party systems contracted by insurers to pre-approve various high-end imaging studies may actually improve both clinical and administrative communication and may lead to improved efficiencies for a radiology practice.
One would also wonder how the frequent interruptions and distractions that affect a radiologist’s workflow might interfere with communication (see our July 1, 2014 Patient Safety Tip of the Week “Interruptions and Radiologists” and our November 2014 What's New in the Patient Safety World column “More Radiologist Interruptions”). While the studies we cited in those columns were primarily about interruptions occurring during overnight shifts in hospitals, such interruptions undoubtedly occur frequently even during daytime working hours in radiology departments or ambulatory radiology practices.
One patient safety tool we often utilize – the checklist – is probably underutilized in radiology practices. While some use checklists to help address all necessary components of radiology reports and checklists are often used for interventional radiology procedures, there is probably more opportunity for use of checklists for the more mundane day-to-day radiology procedures. Checklists are already widely used in MRI suites to ensure patients with ferromagnetic materials are not exposed to magnets. Schedulers can use checklists to ensure completeness of the requisition and coordination of any pre-study preparation with patients. Radiology techs can use checklists to ensure specific items are not overlooked prior to studies (eg. checking serum creatinine before studies involving intravascular contrast, checking to see if patient might be pregnant before some studies, etc.).
There are several types of communication error not really addressed in the Siewert study. In our October 22, 2013 Patient Safety Tip of the Week “How Safe Is Your Radiology Suite?”, among several of our other radiology suite safety columns listed below, we noted that many of the things that go wrong in the radiology department have little to do with radiology. The radiology suite just happens to be a location in which very sick patients with multiple ongoing interventions congregate temporarily. Adverse events like falls, medication errors, patient mixups, IV connection errors, running out of oxygen, conscious sedation incidents, suicides, and others may occur in the radiology suite and communication errors likely play a role in all of these. In particular, a “Ticket to Ride” type checklist is a valuable tool to promote communication of potential things that might go wrong while a patient is in the radiology suite. We refer you to the column above for a comprehensive discussion of what can go wrong in the radiology suite.
Radiology departments and ambulatory radiology practices should include audits in their monthly quality improvement activities to assess how often communication errors are occurring. You’ll probably find that the time invested in doing such audits is more than offset by the time savings you’ll see in improved efficiencies and better patient care. And while the studies cited in today’s column may indicate progress in communicating test results, look at our prior columns listed below for ensuring you have in place systems for failsafe communication of test results so that no patient “falls through the cracks”.
See also our other columns on communicating significant results:
And some of our other columns on interruptions and distractions affecting radiologists:
Some of our prior columns on patient safety issues in the radiology suite:
Siewert B, Brook OR, Hochman M, Eisenberg RL. Impact of Communication Errors in Radiology on Patient Care, Customer Satisfaction, and Work-Flow Efficiency. American Journal of Roentgenology 2016; 206: 573-579
Harvey HB, Tomov E, Babayan A, et al. Radiology Malpractice Claims in the United States From 2008 to 2012: Characteristics and Implications. Journal of the American College of Radiology 2016; 13(2): 124-130