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Failure to Close the Loop on Critical Findings Leads to Negligent Patient Death

March 26, 2021

Delayed communication of critical result claims frequently involve radiologists who fail to close the communication loop (i.e., fail to obtain an acknowledgement that the ED physician read and understood the finding). Closing the loop may seem redundant because radiology reports can often be created, finalized, and posted in the EHR in near real-time;1 however, redundancy in a system increases patient safety and reduces malpractice risk.

asian-doctors-discussing-patient-case_socClosing the loop is particularly important in high-risk interactions such as communication of critical results between radiology and emergency departments. In the following case, the radiologist assumed the ED physician who had ordered a STAT head CT scan would access his preliminary report from the EHR, but the preliminary report was never saved to the system. If the radiologist had directly contacted the ED physician with his preliminary findings, the patient may have received life-saving treatment.

More Information About Communicating Critical Findings along the Continuum of Care

Overview: Healthcare Communication: Case Studies and Best Practices for Communicating Critical Findings

Part 1: From Radiology to ED

Part 2: From Anatomic Pathologist to Ordering and Primary Care Physician

Part 3: From Primary Care Physician to Patient

Allegation

The radiologist negligently failed to communicate his CT scan findings to the ED physician.

Case File

The radiologist opened a STAT head CT scan to evaluate for brain injuries following head trauma. He believed the images showed a possible intracranial hemorrhage and quickly dictated a report recommending further studies. He tried to call the ED but was put on hold. He finally hung up the phone and went to work on his other reports. (It was his understanding the ED physician would be able to retrieve his transcribed report in the system within minutes.) Either because the radiologist failed to save his work at some point or because the EHR system malfunctioned (the radiologist was aware of glitches in the EHR system causing reports to occasionally disappear), the report was not available when the ED physician looked for it in the EHR.

According to ED policies and procedures, ED physicians were required to obtain the results of any radiology studies suggestive of brain injury prior to consulting with a neurosurgeon for head trauma. Prompted by the patient’s family, who had been waiting for the results of the CT scan for several hours, the ED physician contacted the radiology department to ask why the report was not in the system. He was told the images had been reviewed, but no report was in the system. By this time, the radiologist who had first interpreted the images had gone off shift so the ED physician requested a second interpretation of the CT scan.

Based on the second radiologist’s findings, which were identical to those of the first radiologist, the ED physician ordered additional studies and requested a neurosurgery consult. As the patient was being transported for additional studies, he coded and could not be revived. His death was attributed to a subdural hematoma. The patient’s family filed a lawsuit against the ED physician, hospital, and radiologist. They alleged the delay in communication of the findings on the CT scan to the ED physician was negligent and delayed the diagnosis and treatment of the patient’s brain hemorrhage, which would have been treatable if diagnosed in a timely manner.

Discussion

The radiologist’s failure to directly contact the ED physician with his findings significantly complicated the radiologist’s defense in this case. In the first place, the CT scan was ordered STAT and the findings were critical. According to hospital and radiology group policy, the radiologist should have directly communicated the findings to the ordering physician within an hour. Because there was a slight possibility the initial report would not be available to the ED physician because of known EHR problems, the radiologist should have made an extra effort to reach the ED physician instead of assuming the ED physician could access the report for himself.

Although it may have been difficult getting through, it was the radiologist’s responsibility to directly communicate the results to the ED physician. The ED physician’s inexplicable and indefensible delay in following up on the results and the hospital’s failure to solve the problem with its EHR system also contributed to the adverse outcome but did not excuse the radiologist’s contribution to the treatment delay.

Medical Liability Risk Management Recommendations

Radiologists should ensure that critical results are received and understood by a clinician who can act on them for the patient’s benefit. Loading a report into the EHR does not close the communication loop. Consider the following recommendations.1,2,3,4,5

  • Communicate critical findings pursuant to hospital or practice communication policies when appropriate.
  • Work with the administration to make communication protocols more effective if necessary.
    • If protocols or policies are ambiguous, seek clarification.
  • Follow clinical guidelines for reporting findings (e.g., the ACR Practice Parameter for Communication of Diagnostic Imaging Findings) when appropriate.
  • Err on the side of caution with critical results communication. If a finding requires urgent intervention, inform the ED physician by telephone without delay:
    • Identify yourself.
    • State the emergency nature of the call.
    • Verify the name of the person receiving the report.
    • Provide the name of the test and the test results.
    • Ask the person receiving the report to read back the patient’s name and the critical result.
  • Document the actual (or attempted) direct communication with the ED physician, designated ED physician proxy, or patient. Place that documentation in the diagnostic report or in the location designated in the critical results policy.
    • Documentation should include (at a minimum):
      • The words “Critical Result” as a lead off to the documentation
      • The name of the person to whom the results were reported
      • The date and time
      • The method of communication
      • What was discussed
      • An assertion that the communication was understood
    • Customize critical result documentation macros to include appropriate elements of documentation.

One way hospitals and imaging departments can reduce the risk of delayed communication of critical results is by implementing an electronic critical test results management (CTRM) system. CTRM software — also referred to as critical tests reporting and closed-loop reporting software — helps prevent delayed communication of critical results. For example, some systems alert the proper physician directly when a critical result is discovered by the radiologist while others alert administrators who facilitate direct communication between the radiologist and referring physician. These systems can help radiologists close the communication loop.6

This content originally appeared as part of the February 2017 release of the NORCAL Group Risk Management publication, Claims Rx, “Communicating Critical Findings — A Three-Part Series, Part 1: Radiology to ED.” This release and many others are available in the Claims Rx Directory for download. Policyholders will also find instructions for obtaining CME credit for select releases.

References

1. David L. Weiss, et al. “Radiology Reporting: A Closed-Loop Cycle from Order Entry to Results Communication.” Reference Guide in Information Technology for the Practicing Radiologist. 2013. DOI: 10.1016/j.jacr.2014.09.009

2. The Joint Commission. “National Patient Safety Goals for the Hospital Program.” National Patient Safety Goals. Goal 2, NPSG.02.03.01. Effective January 1, 2021.

3. American College of Radiology. ACR Practice Parameter for Communication of Diagnostic Imaging Findings. (Resolution 11) 2014.

4. Lukasz S. Babiarz, et al. “Neuroradiology Critical Findings Lists: Survey of Neuroradiology Training Programs.” American Journal of Neuroradiology. 2013;34: 735-739. DOI: 10.3174/ajnr.A3300

5. Stacey A. Trotter, et al. “Determination and Communication of Critical Findings in Neuroradiology.” Journal of the American College of Radiology. 2013;10(1):45–50. DOI: 10.1016/j.jacr.2012.07.012

6. Alyssa Martino. “Getting the Message: How Can Radiologists Best Communicate Critical Test Results?ACR Bulletin. 2015, 3.

Filed under: Patient Care

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