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SPOTLIGHT CASE
CE/MOC

The Consequences of Miscommunication Regarding a Possible Artifact

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Kriti Gwal, MD | June 30, 2021
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Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), the University of California, Davis, Health must ensure balance, independence and objectivity in all its CME activities to promote improvements in health care and not proprietary interests of a commercial interest.  Authors, reviewers and others in a position to control the content of this activity are required to disclose relevant financial relationships with commercial interests related to the subject matter of this educational activity.  The Accreditation Council for Continuing Medical Education (ACCME) defines a commercial interest as “any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on patients” and relevant financial relationships as “financial relationships in any amount occurring within the past 12 months that create a conflict of interest.   

Kriti Gwal, MD; Patrick Romano, MD, MPH; Debra Bakerjian, PhD, APRN, RN; Ulfat Shaikh, MD; for this Spotlight Case and Commentary have disclosed no relevant financial relationships with commercial interests related to this CME activity.

Learning Objectives

  • Discuss the importance of miscommunication in radiology as a contributor to medical malpractice risk, sentinel events, and delays in diagnosis and treatment.
  • Describe the importance of effective communication between radiologists and referring clinicians.
  • Explain clinical criteria for urgent communication and “closed loop” communication between radiologists and referring clinicians.
  • Identify specific approaches to facilitate effective communication among radiologists, referring clinicians, and patients, to reduce communication-related errors.

The Case

A 52-year-old man complaining of intermittent left shoulder pain for several years presented to an orthopedic surgeon’s office. He was diagnosed with a rotator cuff injury and underwent left shoulder surgery. The postoperative course was unremarkable. Four months later, the orthopedic surgeon ordered a routine follow-up X-ray of the left shoulder. The radiologist interpreted the film as a normal left shoulder radiograph but noted a “… soft tissue density in the left suprahilar region most probably artifact, however follow-up chest X-ray is advised for further evaluation.” This report along with the images were sent to the orthopedic surgeon’s office the same day. However, the orthopedic surgeon independently read and interpreted the same images as “slight loss of rotator cuff interval added to decompression of AC joint and undersurface of the acromion noted.'' The surgeon did not mention any soft tissue density, did not reference the radiologist’s report, and did not order any follow-up study.

The patient saw the orthopedic surgeon multiple times after the initial follow-up X-ray without any knowledge of or follow-up for the “soft tissue density” in the left suprahilar region. Several months later, the patient’s primary care provider noted the radiologist’s finding during a routine visit for healthcare maintenance, and ordered a proper workup. Following needle biopsy guided by computed tomography, the lung mass was diagnosed as a Stage IIB adenocarcinoma with metastasis to one of ten parabronchial nodes. This diagnosis was quickly followed by surgical resection and several courses of chemotherapy. Upon review of the images, the mass had grown from an initial diameter of 3.5 cm to 7.0 cm just before resection.

The Commentary

In radiology, communication errors are considered one of the most important causes of sentinel events in a hospital setting, i.e., events that result in harm or death to the patient, or otherwise signal the need for immediate investigation and response.1,2 In fact, the Joint Commission determined that errors in communication contributed to about 64% of all such events in 2013-2014,1 and 81% of the subset of events where delays in treatment resulted in death or permanent loss of function, as in the present case.3,4 Communication errors can occur in multiple situations but transitions of care from one team to another remain a particularly weak point during which errors may occur.2 In situations involving a consulting clinician, the care of the patient often shifts to the radiologist and then back to the referring clinician via the radiology report; thus, the radiology report serves as an important means of communicating information.4 It can also, unfortunately, serve as a source of communication errors, as this case illustrates.

“What We’ve Got Here is Failure to Communicate”

Communication, by definition, is delivering or exchanging information and, therefore, two individuals or parties are involved.4 The two principal communicating parties in this case are the radiologist and the referring clinician. Radiologists are responsible for the production and delivery of the radiology report, and referring clinicians are responsible for obtaining and reading radiologists’ reports.5 Both radiologists and referring clinicians are legally responsible for retaining and being able to produce the radiology reports.5

Multiple types of communication errors involving radiology can occur.2 There can be failure to communicate critical findings to the primary care provider, or incorrect findings can be communicated.2 In a study from one major academic medical center in 2016, the most frequent problem was lack of sufficient communication by the radiologist, accounting for about 47% of communication-related errors.2 Although some communication errors may have little or no clinical impact, others can result in sentinel events and thus have devastating results.2 For example, lack of sufficient communication between radiologists and referring clinicians may cause delays in diagnosing malignancies or other conditions warranting urgent interventions such as surgical procedures.2

In this case, the radiologist fulfilled their basic responsibilities,4 but communication involves both sending and receiving information. Referring clinician have a duty to review and consider specific recommendations that they receive from radiologists. A recent survey conducted in Australia and New Zealand, the first to directly assess the attitudes of orthopedic surgeons towards radiology reports, revealed that the majority of the 200 orthopedic surgeons surveyed did not routinely read radiology reports.6 Only 18.5% of the surveyed surgeons reported that they always read the radiologist’s report while 2% never read the radiologist’s report.6 To improve patient safety, non-radiologist clinicians who choose to interpret radiographs should always read the final report sent by the radiologist. Any point of disagreement between the radiologist and the referring clinician should be discussed and clearly documented in the health record. Radiologists provide structured interpretations of images based on their formal education and experience. In this case, the orthopedic surgeon did not have training in interpreting chest imaging findings, and therefore should have read and acted upon the radiologist’s finding.

Approach to Improving Safety & Patient Safety Target

Given the importance of communication between radiologists and referring clinicians , the American College of Radiology formed the Actionable Reporting Work Group, which categorized communication methods comprising best practices for radiologists to follow.3 A summary of the Group's findings, in terms of the timing of communications, follows:

  • Within Minutes

    • Communicate findings which could lead to mortality or morbidity if not immediately acted upon by the referring clinician.

      • Findings that suggest a need for immediate or urgent intervention (as per ACR guidelines) include:

        • Ectopic pregnancy
        • Intracranial hemorrhage
        • Pulmonary embolus
        • Ruptured aortic aneurysm
        • Severe cord compression
        • Malpositioned lines or tubes
        • Tension pneumothorax
        • Testicular/ovarian torsion
        • Unexplained pneumoperitoneum
        • Unstable spine fracture
  • Within Hours
    • Communicate clinically significant findings, which:

      • May not urgently affect the patient’s presentation
      • May need specific treatment
    • Provide direct communication through:
      • A finalized report (may suffice), or
      • A preliminary report (by secure fax), or
      • Another locally defined method of communication
  • Within Days
    • Communicate findings which may not need immediate treatment, including:

      • Those that may eventually become significant after time
      • Incidental or unexpected findings
      • Findings with increased risk of being missed such as those that may not directly relate to clinical presentation

In addition to emphasizing the timeliness of communications, these guidelines are intended to ensure that results are communicated to the referring clinician (or if not available, the patient) in a manner that can be readily understood.7,8

Although the radiology report is the most common method of communication between referring clinicians and radiologists, some cases warrant other forms of communication between the radiologist and the referring clinician.8 When the results include emergent or critical findings, the radiologist should communicate directly with the referring team and document that such direct communication took place in their report.8 Although the telephone has been the traditional mode of direct communication, new digital means of communication, described further below, are now available to communicate noncritical or less urgent results.9

In this case, it is debatable (in terms of current best practices) whether the radiologist should have called the referring clinician. As the abnormal finding of a “soft tissue density in the left suprahilar region” was attributed to a probable artifact, some radiologists would consider it adequate to describe the finding and to suggest follow-up in the written report, which is what happened in this case. However, the radiologist in this case was also implicated in the civil suit filed by the patient, suggesting that additional communication is desirable whenever follow-up or intervention is advised.

In general, radiologists are encouraged to close the communication loop with the referring clinician whenever imaging reveals an unexpected incidental finding or any finding that may change management for the patient.5Closed loop” communication includes not just transmission of results but also verbal or written acknowledgement of those results by the recipient.7,9 Nondiagnostic examinations may require “closed loop” communication with the referring clinician when a repeat examination or a different examination is recommended for follow-up.5

Unfortunately, radiologists can have difficulty reaching referring clinicians to directly communicate results. For example, a qualitative study of 12 radiologists at a Swedish university hospital documented delays stemming from either inadequate or incorrect clinician contact information, or lack of response by the clinician or clinician's office.9 Thus, improving the lines of communication between radiologists and referring clinicians is another target for improving patient safety. Finally, if the referring clinician or primary care provider (PCP) is still unreachable, contacting the patient directly to communicate results and recommendations could be a viable alternative for radiologists.5,8

Systems Change Needed

Multiple approaches should be taken to address the communication issues illustrated by this case. The Swiss cheese model, which demonstrates how systems with multiple checks in place can prevent errors, is a good model to use in designing and implementing multiple communication safeguards for improving patient safety.10 This model includes system checklists, each of which acts as a defense against errors that may penetrate the system.9 To both support productivity and efficiency, and to decrease the risk of communication error,11 methods for streamlining and improving communication among radiologists, referring clinicians and patients should be incorporated into a systems-level model for improving patient safety.

The first barrier to communication-related harm is the radiologist’s report. The radiologist should provide a well written, comprehensive report that includes a succinct impression and recommendations for the most appropriate follow-up evaluation or imaging test, when necessary.5 The final report should be sent to the referring clinician,4 but to provide an added layer of defense, the report can also be sent to the PCP, if different than the referring clinician. In this case, it was the patient’s PCP who read the radiologist’s report and then ordered the necessary follow-up examination.

As attempting to reach the referring provider can sometimes be onerous, a radiology assistant can serve as an important safeguard for effectively communicating radiology results. Reading room assistants support radiologists and can help connect the referring clinician to the radiologist, reducing disruptions and time waiting on the telephone. Newer electronic methods can also be used to help ensure effective communication at the systems level. For example, radiologists can use electronic health records to flag automatically or contact referring clinicians and/or PCPs if a follow-up test is recommended. Although this safeguard is a one-way method of communication, the communication loop could be closed by an assistant on either side. Secure text messaging platforms offer another e-method that can be used by radiologists to communicate non-urgent findings and recommendations, and to receive confirmation of receipt of findings. A third e-method entails placing the radiologist’s recommendation into the picture-archiving and communication system (PACS), along with a phrase or symbol combination that could be used for searching. An administrative person would then verify that the recommended follow-up test had been performed, serving as another system check for errors. If the test has not been performed, the administrative person or radiologist would then contact the referring provider for closure of the communication loop.

The advent of direct release of reports to patients should also decrease the risk for communication errors.12 As patient empowerment has become more important in healthcare, this practice provides another level of protection to help prevent errors due to lack of effective communication.9,10,12 In fact, the direct release of reports to patients through patient portals, which is now a routine practice, may encourage increased communication between the patient and the referring clinician, and between the patient and the radiologist.12

Take-Home Points

  • Timely and adequate communication between referring clinicians and radiologists is essential for providing safe and effective care in follow-up to imaging tests.
  • The American College of Radiology’s Actionable Reporting Work Group has described communication methods comprising best practices for radiologists to follow, depending on the urgency of the findings.
  • Responsibility for communicating imaging results and arranging follow-up lies with both the radiologist and the referring clinician; “closed loop” communication may be advantageous for findings that affect management or necessitate follow-up testing.
  • Clinicians who are not radiologists but who interpret the radiographs that they order should also read the final reports sent by radiologists and follow up on their recommendations, as indicated.
  • Improving communication by implementing multiple systems-based changes, using both e-methods and more traditional approaches, could decrease risks associated with communication errors in radiology.

Kriti Gwal, MD
Assistant Professor of Pediatric Radiology, Pediatric Neuroradiology
Department of Radiology, Division of Pediatric Radiology
UC Davis Health
kgwal@ucdavis.edu

References

  1. The Joint Commission. Sentinel event statistics data: root causes by event type (2004-2014). The Joint Commission website. Available at: www.jointcommission.org/assets/1/18/Root_Causes_by_Event_Type_2004-2014.pdf. Accessed June 2021.
  2. Siewert B, Brook OR, Hochman M, et al. Impact of Communication Errors in Radiology on Patient Care, Customer Satisfaction, and Work-Flow Efficiency. AJR Am J Roentgenol. 2016; 206 (3): 573-579.
  3. Larson PA, Berland LL, Griffith B, et al. Actionable Findings and the Role of IT Support: Report of the ACR Actionable Reporting Work Group. J Am Coll Radiol. 2014; 11: 552-558.
  4. “Communication.” Merriam-Webster.com Dictionary, Merriam-Webster. Available at: https://www.merriam-webster.com/dictionary/communication. Accessed May 2021.
  5. Babu AS, Brooks ML. The Malpractice Liability of Radiology Reports: Minimizing the risk. Radiographics. 2015 Mar; 35 (2): 547-554.
  6. Kruger P, Lynskey S, Sutherland A. Are orthopaedic surgeons reading radiology reports? A Trans-Tasman Survey. J Med Imaging Radiat Oncol. 2019 Jun; 63 (3): 324-328. doi: 10.1111/1754-9485.12871.
  7. The Joint Commission. Sentinel Events. Available at: https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/. Accessed May 2021.
  8. American College of Radiology (ACR). ACR Practice Parameters for Communication of Diagnostic Imaging Findings (Revised 2020). Available at: https://www.acr.org/-/media/acr/files/practice-parameters/communicationdiag.pdf. Accessed May 2021.
  9. Fatahi N, Krupic F, Hellström M. Difficulties and possibilities in communication between referring clinicians and radiologists: perspective of clinicians. J Multidiscip Healthc. 2019; 12: 555-564. doi:10.2147/JMDH.S207649.
  10. Collins SJ, Newhouse R, Porter J, Talsma A. Effectiveness of the surgical safety checklist in correcting errors: a literature review applying Reason's Swiss cheese model. AORN J. 2014; 100 (1): 65-79.e65. doi:10.1016/j.aorn.2013.07.024.
  11. Larson DB, Froehle CM, Johnson ND, et al. Communication in Diagnostic Radiology: Meeting the Challenges of Complexity. AJR Am J Roentgenol. 2014; 203 (5): 957-964.
  12. Reiner BI. Strategies for radiology reporting and communication. Part 1: challenges and heightened expectations. J Digit Imaging. 2013; 26 (4): 610-613. doi:10.1007/s10278-013-9615-6.
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This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
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