Misread scans and films are the leading cause of patient injury involving diagnostic radiologists, according to a recent analysis of closed malpractice claims.1

“Radiology as a specialty has been experiencing higher-than-anticipated losses,” says study author Darrell Ranum, JD. Ranum is former vice president of patient safety and risk management at the Doctors Company, a Napa, CA-based medical malpractice insurer, which sponsored the analysis.

More claims and higher indemnity payments were happening than in the recent past. The insurer decided more data were needed. The analysis revealed poor communication between providers was one of the key contributing factors to the lawsuits. “We expected that the communication problem would be between the radiologist and attending physician when reporting important findings,” Ranum says.

Those communication breakdowns do occur. But the study showed a different communication problem. Communication between ordering emergency physicians (EPs) and radiologists was problematic. The issue is the ordering EPs are unclear on the reason for ordering the imaging studies. “Radiologists were often left guessing as to what the attending physician was trying to learn,” Ranum explains.

The American College of Radiology recommends ordering clinicians include a working diagnosis, pertinent clinical symptoms, and specific questions to be answered.2 For the emergency department (ED) in particular, Ranum recommends the following:

  • EPs should provide clinically relevant information when ordering imaging studies;
  • EPs should consider calling radiologists for suspected conditions that are unusual to help radiologists reach accurate findings;
  • When radiologists discover serious findings for ED patients, they should call EPs to make sure the information reaches them;
  • If the ED patient has been discharged already, radiologists and EPs should determine who will convey the information to the patient’s personal physician and/or the patient;
  • When receiving calls from radiologists, EPs should repeat the findings to confirm the information was understood.

The analysis also revealed patients themselves contributed to the problem by not showing up for scheduled appointments or follow-up studies. Ranum could not determine why. “We can only speculate that patients either did not understand the findings, did not comprehend the importance of the follow-up studies, or they could not afford to pay for additional studies,” Ranum offers.

Radiology malpractice claims in the ED usually are made for one of two reasons, says forensic consultant Jonathan D. Lawrence, MD, JD, FACEP. Either the EP misreads the study, and is never picked up by the radiology overread, or the radiologist finds something incidental, but never contacts the EP to recommend a follow-up. “The key to both of these is communication. ERs [emergency rooms] and radiology need an ironclad procedure for X-ray discrepancies,” Lawrence stresses.

In some EDs, the EP never sees the actual X-ray and relies solely on the radiology report. “The ER doctor is off the hook as far as misreading the X-ray, but will still be named in the lawsuit,” Lawrence explains.

Since the EP had nothing to do with the misread, relying entirely on the radiologist’s reading, the defense attorney probably can find a way to dismiss the EP from the litigation. “But nonetheless, time, energy, and anxiety still accompanies being named in the lawsuit,” Lawrence cautions.

If the EP reads the X-ray, then the radiologist overreads it, a few things need to happen to reduce risks. The EP’s reading needs to be clear to the radiologist. “I have reviewed many charts of ED colleagues where the X-ray reading is not documented. The radiologist can’t see it,” Lawrence recalls.

If a discrepancy is noted, the radiologist needs to make sure the EP knows about it. The next question is what the EP does about it. If the radiologist picked up a missed fracture for a discharged ED patient, that patient needs to be told about the finding. “Even if it’s picked up relatively quickly — the next day — the attorney will say that the delay caused worsening of the injury,” Lawrence reports.

The disclaimer ED discharge instructions typically state radiology will review X-rays and that patients will be notified if there is any discrepancy. “If this doesn’t happen, then the hospital is on the hook because of the promise they made to the patient,” Lawrence says.

REFERENCES

  1. Ranum D. Diagnostic and interventional radiology closed claims study. The Doctors Company. https://bit.ly/3071C1Q
  2. American College of Radiology. ACR practice parameter for communication of diagnostic imaging findings. Revised 2014.