Missed Radiology Finding? Process Needed to Inform Patients
Good communication prevents suits
An emergency physician (EP) caring for a 62-year-old man after a motor vehicle accident interpreted the chest X-ray as negative. The radiologist overreading the chest films the next day noted a left lung nodule, but the patient was never notified.
During a second ED visit, a large mass on the left lung was noted by the radiologist; but again, this was not communicated to the patient. "Even though the X-rays were obtained during ED visits, results in both situations were forwarded to the primary care physician, who failed to act on the findings," says Jeanie Taylor, RN, BSN, MS, vice president of risk services for Emergency Physicians Insurance Company (EPIC) in Roseville, CA.
The patient died of lung cancer two years later, and the family sued the EP, the radiologist, and the primary care physician. "The case settled for a large amount," says Taylor.1
EPs usually have the benefit of a radiologist interpretation prior to patient discharge, with the exception of reading of plain films on nights, weekends, and holidays. "These may be read by the EP on duty, and then later overread by a radiologist," says Taylor.
Research suggests that EPs are very good at reading plain films, but more commonly overlook abnormalities on chest X-rays, such as nodules and masses.2
"The best way to avoid malpractice claims involving missed radiology findings is to be sure that when a miss occurs, you have a good process in place to notify the patient," says Taylor. She offers these risk-reducing strategies:
• EDs should have a consistent process to identify discordant interpretations and notify patients of these.
A specific person, or position, in the ED must be responsible to review and follow-up on discrepancies every day, including holidays and weekends.
Damages and claims can be averted if there is a robust follow-up system in place ensuring that cases in which there is a discrepancy between the EP and the radiologist are identified and acted upon, says Taylor.
"If such a process is lacking and key radiology findings fall through the cracks, identifying an effective defense strategy is challenging if a claim is filed," says Taylor.
• Radiology and the emergency department must agree on a protocol for critical findings.
Taylor says that when a lung nodule is incidentally identified by the radiologist, this should be considered a critical finding. "There are too many cases where a missed nodule is not communicated to a patient, and too often with deadly results," she says.
• EPs should not rely on the primary care provider to follow-up with the patient.
"It’s really very simple. You ordered the test and you are responsible for the follow-up," says Taylor. "Relying on the patient’s physician to notify the patient of test results from a test you ordered is just not a good practice, nor is it is a good defense if the patient is not notified."
Document all calls to the patient, whether they are part of your routine call-back process, or to notify the patient of a missed X-ray finding, she advises.
• EDs should make the EP’s interpretation immediately available to the reading radiologist.
Electronic medical records and radiology archiving and communication systems can be helpful in ensuring appropriate follow-up, but can create problems if the ED has failed to amend its old process to work with the newer technology.
Staff radiologists have the ability to go into the ED electronic record to review the EP’s notes, but don’t always take the extra time to do so.
"The fact is that if the radiologist has to go into the electronic ED record to retrieve the EP’s interpretation, they may not take this extra step," she says. "Thus, they are unaware of what the EP told the patient."
If the radiologists have the EP’s interpretation when they read the films, they know right away when a discrepant reading has occurred, such as a missed fracture.
"EDs need to work with their IT departments to ensure that the radiologist is provided with the EP’s interpretation, instead of having to sign in and access the actual ED record, which can sometimes be cumbersome," says Taylor.
Stop Missed Fracture Suits
EDs should implement a process in which patients with fractures, or potential fractures, are called back the next day to ask how they are doing and ensure they are getting appropriate follow-up, advises Taylor.
"This allows an opportunity to intervene if the patient reports increased pain or other indications that something may have been missed," she explains. Here are some practices to consider to prevent claims alleging missed fractures:
• Explain to the patient that while you didn’t see a fracture, a radiologist will also look at the films.
"Tell the patient that if the radiologist notices anything abnormal, you will let them know," says Taylor. "By communicating in this manner, you have set the stage for a missed finding."
If patient is later told that a fracture was identified by the radiologist, the patient will see the EP as the person who facilitated the fracture being identified, instead of the one who missed it, says Taylor.
• Treat injuries as if a fracture is present.
"Use splints and immobilization," says Taylor.
• If you are in doubt, contact the radiologist on call to read the films in real time.
"Being a nice guy’ by trying not to bother on-call staff and physicians is not in your, or the patient’s, best interest," says Taylor.
• Arrange timely follow-up.
"Instructions for the patient to see their doctor in a week if their symptoms do not improve is not adequate," she warns. "And it will not protect you if there is a bad outcome and subsequent litigation." n
1. Wright J. Physicians unaware of nodule on routine X-ray. Retrieved from http://www.rmf.harvard.edu/clinician-resources/case-study/2006/physicians-unaware-of-nodule-on-routine-xray.
2. Petinaux B, Bhat R, Boniface K, et al. Accuracy of radiographic readings in the emergency department. Am J Emerg Med. 2011;29:18-25.
For more information, contact:
• Jeanie Taylor, RN, BSN, MS, Vice President, Risk Services, Emergency Physicians Insurance Company, Roseville, CA. Phone: (530) 401-8103. E-mail: email@example.com.