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Discrepancies in Readings of ED X-rays Pose Risks
Patients can be harmed
After the emergency physician's (EP) preliminary reading of a seizure patient's X-ray was negative, the patient was discharged, but the following day, the radiologist's report showed compression of the spine.
"The results weren't conveyed to the EP who had ordered the test," says Denise Martindell, RN, JD, a patient safety analyst at ECRI Institute under contract for the Pennsylvania Patient Safety Authority based in Harrisburg, PA, which collects data on near-misses. "This would have resulted in a potential delay in diagnosis." In this case, the patient came back to the ED several days later and was admitted for neurosurgical intervention, says Martindell.
About one-third of the discrepancies between an EP's opinion of an X-ray and the final opinion from a radiologist involved a potentially significant clinical finding, such as a fracture, pneumonia, or appendicitis, according to an analysis of 195 reports submitted in 2008 to the Pennsylvania Patient Safety Authority.1
Patients may be harmed if a discrepancy is not appropriately communicated between the radiology department and ED, warns Martindell, the Advisory's author.
"A process must be in place for radiologists to communicate such discrepancies in a timely manner to EPs," she says. "This ensures patients will receive appropriate follow-up care."
Communication was a factor in 28% of the discrepancies, with significant clinical findings that weren't followed up on, according to Authority reports. "We so often find that communication between providers is a contributing factor to adverse events," says Martindell. "We do find that consistently." She recommends standardizing communication between radiology and the ED, as a risk-reduction strategy.
The ED's system for this may vary, notes Martindell, depending on factors such as availability of an electronic medical record. Regardless, she says that policies and procedures must be applied consistently across shifts.
"It doesn't matter what type of technology you have. Some facilities have electronic transfer of X-rays to radiology, and some don't," says Martindell. "It really is incumbent on the ED to have a process to consistently make that happen."
Breakdowns Can Occur
Martindell says that communication breakdowns can occur in "the first link in the chain" when the ED is transmitting the report for interpretation to radiology, or the next step, when the radiologist's interpretation comes back to the ED.
Potential liability exposures for EDs for either of these scenarios include potential delay in diagnosis, failure to diagnose, and misdiagnosis, she says.
"We have seen reports of the radiologist's report not being timely, or the ED not receiving it at all," she says. "The reasons for that would vary by the institution, but the ED generated the X-ray. So it is incumbent on the ED to make sure it's acted upon."
The ED must have a process for reconciling the radiologist's final interpretation with the care the patient received, advises Martindell. Any verbal communication between the ED and radiology should be documented, she adds.
"The other piece where the system can break down is from the ED to the subsequent treating provider," says Martindell. "This is the last step in the communication chain. Each step in this chain is as important as the next."
When the EP sees the radiologist's interpretation, he or she must reconcile this with the patient's medical record, Martindell explains. Since the patient probably will have been discharged already, she says, there has to be a system for notifying the subsequent treatment physician or the patient.
Potentially successful approaches include having the ED physician, a designated nurse, or other individual do this, says Martindell. "Different EDs have different ways of doing this," she says. "It is important to document the attempts to reach the patient. The process should include the subsequent treating physicians. Contact with subsequent providers is very important."
1. Matindell D. Communication of radiographic discrepancies between radiology and emergency departments. Pa Patient Saf Advis 2010; 7(1):18-22.
For more information, contact:
Denise Martindell, RN, JD, Patient Safety Analyst, Plymouth Meeting, PA. Phone: (610) 825-6000 ext. 5246. Fax: (610) 567-1114. E-mail: email@example.com.