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Failure to Communicate Critical Radiology Findings Leads to Loss of Testicle

March 26, 2021

In the following case study, the radiologist’s critical finding was not communicated to the ED physician in time to treat the patient before progression of his condition resulted in permanent injury.

Like so many other adverse outcomes, this one was caused by a combination of systems and human errors. The critical results communication policies and procedures were inadequate, the radiologist misunderstood his direct communication duties, and the ED physician forgot to check for the radiology results when he hadn’t heard from the radiologist after a few hours.

Consider how better communication policies and practices could have averted the poor outcome in the following case.

Allegation

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

The radiologist’s failure to communicate an ultrasound finding of testicular torsion contributed to delayed treatment and loss of the testicle.

Case File

A patient was transported to the ED by ambulance due to sudden and significant pain in his left testicle. During triage, the nurse noted that the patient’s testicle was mildly swollen and very tender to light palpation. The patient reported his pain was a nine on a scale of 1 to 10.

Testicular torsion and acute epididymitis were in the ED physician’s differential diagnosis. He ordered an ultrasound to rule out testicular torsion, as well as IV morphine and warm compresses. The ultrasound demonstrated testicular torsion, which the radiologist noted in his report. The radiologist dictated his report, reviewed the transcription, and saved it in the electronic health record (EHR) within 30 minutes of the ultrasound’s completion. The radiologist did not directly communicate the results to the ED physician.

Several hours later, the ED physician reviewed the report, but it was too late to save the patient’s testicle. The patient sued the ED physician, radiologist, and hospital for delayed diagnosis of testicular torsion.

Discussion

Experts believed the patient’s testicle could have been saved if surgical detorsion had occurred immediately following the detection of the positive ultrasound finding. The radiologist assumed his timely entry of the radiology report into the EHR satisfied his communication duties. Unfortunately, the ED physician was relying on the radiologist to alert him directly to a critical finding. The hospital had a critical result reporting policy, but the radiologist had not reviewed the policy to the extent necessary to understand he should have directly communicated the finding of testicular torsion back to the ED physician as soon as it was discovered.

Medical Liability Risk Management Recommendations — Creating Critical Results Communication Policies and Procedures

The policies and procedures for communicating critical results should allow the radiologist to answer the following questions:1,2

  1. What is the criticality of the finding?
  2. How much time do I have to report it?
  3. To whom should the finding be communicated?
  4. To whom should the results be communicated when the ordering clinician is not available?
  5. How should the finding be communicated?
  6. Has the information been received by the person who can best act on it?

Consider the following recommendations:1,3,4,5,6

  • Create a critical results list and define different levels of criticality.
    • Involve radiologists and emergency physicians in the creation of critical findings lists.
    • Avoid creating a list that is too difficult to use because of its length and detail.
    • Take into consideration the prevalence of findings based on the patient population.
    • Analyze and revise the list regularly to reflect changing practice patterns and disease incidence.
    • Treat the critical findings list as a floor, not a ceiling.
      • Physicians should feel free to use their clinical judgment in determining whether communicating a finding not on the list should be expedited.
    • Ensure that anyone who is involved in ordering and communicating ED patient radiology results is aware of what is on the critical results list and knows how to access it.
  • Define acceptable methods of communication for each category of critical results.
    • Include clear identification and read-back directions for spoken transactions, for example:
      • Identify yourself.
      • State the emergency nature of the call.
      • Verify the identity of the person receiving the result.
      • State the name of the study and the critical results.
      • Request a read-back of the patient’s name and critical results.
      • Document the interaction, including the date, time, and names of both parties.
    • Identify where spoken critical result communications should be documented (e.g., PACS, final radiology report, or log).
  • Define by whom and to whom critical results should be reported.
  • Outline the information that should be included in documentation of direct critical result communication, including:
    • “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
  • Identify who should receive the results if the ordering clinician is not available.
  • Monitor and evaluate critical results communication procedures.
  • Determine whether critical results are being communicated in the time frames designated in the policy.
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. American College of Radiology. ACR Practice Parameter for Communication of Diagnostic Imaging Findings. (Resolution 11) 2014.

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

3. 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

4. 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.

5. 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

6. 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

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