Patient Safety Tip of the Week Archive

Patient Safety Tip of the Week

May 25, 2021

Yes, Radiologists Have Handoffs, Too

We’ve done many columns on handoffs in multiple venues and for various specialties. But we’ve never done one about radiologists. We.ve done multiple columns on radiologists and “closing the loop” to make sure significant imaging findings to not “fall through the cracks”. That process is, of course, a form of handoff. But radiologists also have several other types of handoffs.

A recent article by Burns et al. (Burns 2021) discussed those handoffs in both diagnostic and interventional radiology and offered recommended actions.

One form of handoff is from clinical staff to diagnostic radiology. This includes exam requests, special precautions (like allergies, isolation, etc.), initiation of consults, physical transfers, patient registration and identification, and technologist notes.

These clinician-to-radiology handoffs are critical, given the host of medical problems that may arise in the radiology suite. The vast majority of patient safety issues that arise in the radiology suite have little to do with the radiology procedure itself. Rather, seriously ill patients with complicated problems are sent to radiology and multiple problems can arise while the patient is in the radiology suite. See all our columns on such issues listed below. Intrahospital transport of patients is also a very vulnerable period, and the majority of such transports are to and from radiology. Our multiple columns on the “Ticket to Ride” checklist/handoff (also listed below) have stressed all the considerations when transporting such patients to and from radiology.

We cannot overemphasize the clinician’s role in providing the radiologist with adequate information as to why an imaging study is requested. In the “old days” (before CPOE) a clinician would often simply order an imaging study on the order sheet. Sometimes, then, clerical staff would simply fill out a requisition and under “reason for study” they might just write down the admitting diagnosis. Radiologists thus might get a requisition for a CT scan of the head for “pneumonia”! Fortunately, most CPOE systems and radiology information systems now require the clinician to provide more specific reasons for ordering imaging studies but even that often still just includes selecting a reason from a drop-down menu. The clinician really needs to let the radiologist what he/she is looking for or what he/she is looking to exclude. Often a verbal clinician-to-radiologist communication may be necessary and that further provides an opportunity for the radiologist to suggest the best imaging modality or protocol to use.

Another form of handoff is from radiology to clinical staff. This includes return on consults (communication of choice of appropriate imaging, protocols, follow-up recommendations, etc.). Also included would be preliminary and final reports and communication of significant or unexpected findings (see our columns on closing the loop listed below). It also includes physical transport of the patient from radiology back to the clinicians and nursing staff.

Many of the same items (in both directions) are part of handoffs for interventional radiology. But Burns and colleagues note that for these procedures pre-operative assessment, clinical notes, direct care team sign-outs, and intraprocedural discussions and decisions are also part of the clinician-to-radiologist handoff. In the reverse direction (radiologist-to-clinician) the handoff would also include pre-procedure orders, direct care team sign-outs, post-procedure notes and orders, including monitoring needs and plans for follow-up.

They then discuss adaptation of the Institute for Healthcare Improvement’s (IHI) reliability science framework for improving handoffs in radiology. They discuss 3 key levels of actions to improve handoffs:

Strategies targeted toward the individual
Strategies focused on team behaviors
Strategies targeted toward the organization

Strategies targeted to the individual include training and reminders, standardization, checklists, mnemonics, and active listening skills. They caution about unclear handwritten orders and transcriptional errors and emphasize proofreading reports. Even though voice dictation software has made great strides, we still get reports with some outrageous mistakes. The authors note that transcriptional errors occur in as many as 22% of reports. And, unfortunately, we still occasionally see dictated reports appear in charts stating “signed but not read”. A focus on active listening behaviors is something that should apply to everyone in healthcare, not just radiologists. We always also stress the importance of “read back”, “hear back”, and “repeat back” to help ensure that all parties understand communications.

Checklists are important tools in handoffs. They help remind us to pay attention to details we might otherwise overlook. One checklist they describe for interventional radiology is called RADPASS (Koetser 2013). We’d again recommend use of “Ticket to Ride” style checklists for intrahospital transports (see columns listed below).

Burns et al. also introduced a new mnemonic, I-SCAN, for handoffs in radiology that is designed to incorporate important elements of I-PASS® with a tighter focus on radiologic findings. I-SCAN can be used in both diagnostic and interventional practice. I-SCAN stands for:

I Importance of results and identification of study, patient, sender, receiver

S Summary of imaging findings or interventional procedure

C Clinical context; any questions or additional concerns

A And

N Next steps” (further imaging, clinical workup, other recommendations)

Focus on team behaviors includes designation of time with minimal noise and interruption during handoffs “to ensure that the ideas expressed are completely and clearly reflected”. They suggest this can be achieved in a manner similar to the time-outs used in surgery. They also note that simulation practice is another useful tool.

Strategies targeted toward the organization include steps to promote a culture of safety and “Just Culture”. This encourages error reporting and learning without fear of blame or punishment. Error reporting should include not only incidents with patient harm but also near misses. And non-punitive peer learning also includes communication of “great calls” and “great catches”.

We refer you to the Burns article itself for many details of their strategies. Every radiology department or practice can learn from their work to improve handoffs and patient safety.

And, since we mentioned IPASS®, it’s worth noting that the IPASS® Patient Safety Institute just celebrated its 5-year anniversary. Of course, studies on IPASS® began over a decade ago and it is probably today the most widely used handoff format and system.

In a recent commentary on a study from Argentina (Jorro-Barón 2021) that showed IPASS® implementation in pediatric intensive care units showed significant improvement in handoff compliance but failed to reduced adverse events, Shahian (Shahian 2021) eloquently discusses the problem of linking handoffs to outcomes and events. He describes multiple studies that validate the usefulness of IPASS® and makes a plea for more urgent adoption of its principles to improve handoffs at every level of healthcare.

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”

See also our other columns on communicating significant results:

May 1, 2007 “The Missed Cancer”
February 12, 2008 “More on Tracking Test Results”
October 13, 2009 “Slipping Through the Cracks”
July 2009 “Failure to Inform Patients of Clinically Significant Outpatient Test Results”
March 9, 2010 “Communication of Urgent or Unexpected Radiology Findings”
March 1, 2011 “Tests Pending at Discharge”
August 21, 2012 “More on Missed Followup of Tests in Hospital”
October 2, 2012 “Test Results: Everyone’s Worst Nightmare”
March 12, 2013 “More on Communicating Test Results”
October 2013 “New AHRQ Toolkit: Improving Your Office Testing Process”
January 2014 “Email Alerts for Pending Test Results”
July 2015 “Technology to Avoid Delays in Follow-up of Significant Results”
November 17, 2015 “Patient Perspectives on Communication of Test Results”
December 20, 2016 “End-of-Rotation Transitions and Mortality”
September 2018 “ECRI Institute Partnership: Closing the Loop”
September 24, 2019 “EHR-related Malpractice Claims”
November 26, 2019 “Pennsylvania Law on Notifying Patients of Test Results”
January 2020 “The Joint Commission on Closing the Loop”
September 8, 2020 “Follow Up on Tests Pending at Discharge”
April 13, 2021 “Incidental Findings – What’s Your Strategy?”

Some of our prior columns on intrahospital transports and the “Ticket to Ride” concept:

April 8, 2008 “Oxygen as a Medication”
November 18, 2008 “Ticket to Ride: Checklist, Form, or Decision Scorecard?”
August 11, 2009 “The Radiology Suite…Again!”
March 13, 2012 “Medical Emergency Team Calls to Radiology”
August 25, 2015 “Checklist for Intrahospital Transport”
September 1, 2015 “Smarter Checklists”
November 2016 “Oxygen Tank Monitoring”
February 2018 “Oxygen Cylinders Back in the News”
May 22, 2018 “Hazardous Intrahospital Transport”
October 30, 2018 “Interhospital Transfers”
March 31, 2020 “Intrahospital Transport Issues in Children”
June 23, 2020 “Telemetry Incidents”
July 14, 2020 “A Thesis on Intrahospital Transports”
August 4, 2020 “Intravenous Issues”
February 2021 “Risk from Intrahospital Transfer: Healthcare-Associated Infection”

Some of our prior columns on patient safety issues in the radiology suite:

October 16, 2007 “Radiology as a Site at High-Risk for Medication Errors”
February 19, 2008 “MRI Safety”
September 16, 2008 “More on Radiology as a High Risk Area”
October 7, 2008 “Lessons from Falls....from Rehab Medicine”
October 2008 “Preventing Infection in MRI”

March 17, 2009 “More on MRI Safety”
March 2009 “Risk of Burns during MRI Scans from Transdermal Drug Patches”

August 11, 2009 “The Radiology Suite…Again!”
January 2010 “Falls in the Radiology Suite”
August 2010 “Sedation Costs for Pediatric MRI”
January 25, 2011 “Procedural Sedation in Children”

February 1, 2011 “MRI Safety Audit”
October 25, 2011 “Renewed Focus on MRI Safety”
March 13, 2012 “Medical Emergency Team Calls to Radiology”
August 2012 “Newest MRI Hazard: Ingested Magnets”
October 22, 2013 “How Safe Is Your Radiology Suite?”
February 25, 2014 “Joint Commission Revised Diagnostic Imaging Requirements”
July 2014 “New MRI Risks: for Staff!”
July 1, 2014 “Interruptions and Radiologists”
November 2014 “More Radiologist Interruptions”
October 21, 2014 “The Fire Department and Your Hospital”
June 23, 2015 “Again! Mistaking Antiseptic Solution for Radiographic Contrast”
August 25, 2015 “Checklist for Intrahospital Transport”
March 22, 2016 “Radiology Communication Errors May Surprise You”
August 2016 “Guideline Update for Pediatric Sedation”
October 2016 “MRI Safety: There’s an App for That!”
January 17, ,2017 “Pediatric MRI Safety”
August 8, 2017 “Sedation for Pediatric MRI Rising”
November 14, 2017 “Tracking C. diff to a CT Scanner”
March 2018 “MRI Death a Reminder of Dangers”
March 2018 “Cardiac Devices Safe During MRI But Spinners!?”
April 2018 “Radiologists Get Fatigued, Too”
May 2018 “Cost of Interrupting a Radiologist”
November 2018 “OMG! Not My iPhone!”
December 11, 2018 “Another NMBA Accident”
April 2, 2019 “Unexpected Events During MRI”
September 2019 “New MRI Hazard: Magnetic Eyelashes”
October 15, 2019 “Lots More on MRI Safety”
November 5, 2019 “A Near-Fatal MRI Incident”
November 12, 2019 “Patient Photographs Again Help Radiologists”
November 26, 2019 “Pennsylvania Law on Notifying Patients of Test Results”
January 7, 2020 “Even More Concerns About MRI Safety”
July 14, 2020 “A Thesis on Intrahospital Transports”
August 25, 2020 “The Off-Hours Effect in Radiology”

· October 2020 “New Warnings on Implants and MRI”

· January 2021 “New MRI Risk: Face Masks”

References:

Burns J, Ciccarelli S, Mardakhaev E, et al. Handoffs in Radiology: Minimizing Communication Errors and Improving Care Transitions. JACR 2021; May 11, 2021

https://www.jacr.org/article/S1546-1440(21)00323-9/fulltext

Koetser IC, de Vries EN, van Delden OM, et al. A checklist to improve patient safety in interventional radiology. Cardiovasc Intervent Radiol 2013; 36: 312-319

https://link.springer.com/article/10.1007/s00270-012-0395-z

IPASS® Patient Safety Institute

https://www.ipassinstitute.com/

Jorro-Barón F, Suarez-Anzorena I, Burgos-Pratx R, et al. Handoff improvement and adverse event reduction programme implementation in paediatric intensive care units in Argentina: a stepped-wedge trial. BMJ Quality & Safety 2021; Published Online First: 23 April 2021

https://qualitysafety.bmj.com/content/early/2021/04/22/bmjqs-2020-012370

Shahian D. I-PASS handover system: a decade of evidence demands action. BMJ Quality & Safety 2021; Published Online First: 23 April 2021

https://qualitysafety.bmj.com/content/early/2021/04/22/bmjqs-2021-013314

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