About half (46%) of radiology malpractice claims involve ED patients, according to the results of a recent analysis.1

“There are a disproportionate number of actions arising out of the ED,” says Jeffrey Robinson, MD, MBA, FACR, the study’s lead author and an associate professor in the department of radiology at University of Washington.

As president and founder of Cleareview, a malpractice review consulting company, Robinson noticed many cases involved ED patients. “As I was entering case after case into the Cleareview intake database, it occurred to me that there seemed to be an awful lot of ER cases,” Robinson recalls.

Researchers set out to learn if this anecdotal impression was supported by hard data. Robinson and colleagues analyzed 149 imaging exams occurring during a six-year period from 2012 to 2019. There were 68 claims from the ED, compared to 56 in the outpatient setting and 25 in the inpatient setting. Investigators wanted to verify the prevalence of ED-related malpractice claims truly was disproportionate to the total number of exams performed in the ED. To do this, they used the 2016 Medicare Part B claims database, which is assumed to closely approximate the general population. “We found it was four or five times more likely to have a malpractice action arise out of an ED exam compared to an inpatient or outpatient exam,” Robinson observes.

Previous studies of radiology and malpractice have focused on the type of exams involved in claims. “None talked about whether it was inpatient, outpatient, or ER,” Robinson notes. “This is the first paper to focus on the ER as an independent risk factor.”

Radiologists lacking specific ED expertise are one potential reason for the disproportionate number of claims involving ED patients. “Anytime there’s a malpractice lawsuit involving radiologists, it’s almost always over misinterpretation,” says Robinson, a practicing emergency radiologist at Harborview Medical Center in Seattle.

Expertise and background of radiologists reading ED cases varies widely. Some are subspecialists in neuroradiology, while others are breast imaging specialists. “A lot of the studies are being read by people for whom ER exams are not in their sweet spot,” Robinson explains.

It is not that ED exams are unusually difficult; rather, they vary widely and come at all hours of the day and night. Many radiologists are at the end of an extended day when the late evening head CT comes in. “But that exam is part of the normal workload of someone on a dedicated emergency radiology service,” Robinson adds.

Robinson hopes the study’s findings will raise awareness of emergency radiology as a distinct subspecialty. “Somebody really ought to be focusing their attention on these providers and these patients,” he offers.

One possible approach is for radiology groups to develop a section that is focused primarily on emergency medicine. “They don’t necessarily need to be fellowship-trained,” Robinson suggests. “But a section whose primary customer is the ED is needed.”

Rodney K. Adams, JD, has defended multiple malpractice radiology claims, representing both emergency physicians (EPs) and radiologists. While facts of the cases vary, there is one prevailing theme. “Often, it has to do with lack of communication both ways — between the ER doctor and the radiologist,” says Adams, a visiting assistant professor at the University of Richmond (VA) School of Law. Ideally, the EP gives a relevant clinical context so the radiologist understands what he or she is looking for. However, the way orders are entered in some EDs hinders this. For instance, the EP might ask a nurse or a clerk to obtain a chest X-ray. The order is entered without any clinical history or context on why the X-ray is indicated, other than a generic symptom like “chest pain.”

“If the EP gives the radiologist a specific question, that would draw their attention to it,” Adams says. Even if EPs handle their own ordering, many use template charting, which makes the clinical history difficult to ascertain.

Radiologists may try to access the chart in the electronic health record (EHR), but their systems are not necessarily integrated with the ED’s system. Even if they can view it, time often will not permit a lengthy chart review. “If the radiologist calls to get the history, the ER doctor will likely be tied up with another patient or in the middle of a procedure,” Adams adds.

The same kind of communication gaps exist on the radiology side. For various reasons, radiologists do not always verbally convey the urgency of a finding to the EP. “That’s becoming more of a problem with the EHR,” Adams notes.

The radiologist assumes the EP is going to look at the report at some point prior to discharge. The report is in the EHR, but there may not be anything drawing the EP’s attention to it. “Sometimes, there is something critical in there that the radiologist has identified, but nobody ever picks it up,” Adams says.

Plaintiff attorneys will name both the EP and radiologist, hoping the two defendants will blame one another. In some cases, radiologists testify that if the EP really had a specific concern, the EP should have given a better clinical history.

“Given that they don’t know what else is going on with the patient, the fact that the chest X-ray looks normal doesn’t mean much without the big picture,” Adams explains. In response, EP defendants say they would have expected a call from the radiologist if there was an important finding. “The other thing is that radiologists, trying to hedge their bets, will put in a few disclaimers,” Adams says.

Even something as benign as “correlate clinically” leaves wiggle room for radiologists to argue the EP should have acted. “We can never win a case when the defendants are fighting amongst themselves, with both trying to exculpate themselves,” Adams says.

REFERENCE

  1. Robinson JD, Hippe DS, Deconde RP, et al. Emergency radiology: An underappreciated source of liability risk. J Am Coll Radiol 2020;17:42-45.