---
title: Failure to Follow Critical Results Reporting Policy Leads to Incorrect Diagnosis and Patient Death
description: Failure to communicate chest x-ray findings resulted in the patient’s pneumonia going untreated and ultimately causing his death.
image: https://files.norcal-group.com/hubfs/tired-doctor-at-work-in-medical-office-social.jpg
---

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# Failure to Follow Critical Results Reporting Policy Leads to Incorrect Diagnosis and Patient Death

 March 26, 2021

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Often, when a patient comes to the ED, radiographic studies are interpreted by an on-site radiologist after the patient has been discharged or after the ordering ED physician has gone off shift. Consider how this outcome could have been different if the radiologist or ED staff had followed critical results policies and procedures.

![tired-doctor-at-work-in-medical-office-social](https://files.norcal-group.com/hubfs/tired-doctor-at-work-in-medical-office-social.jpg)

### More Information About Communicating Critical Findings along the Continuum of Care

Overview: [Healthcare Communication: Case Studies and Best Practices for Communicating Critical Findings](https://www.norcal-group.com/library/healthcare-communication-case-studies-and-best-practices-for-communicating-critical-findings?hsLang=en-us)

**Part 1: From Radiology to ED**

- Closed Claim Case Study: [Failure to Communicate Critical Radiology Findings Leads to Loss of Testicle](https://www.norcal-group.com/library/failure-to-communicate-critical-radiology-findings-leads-to-loss-of-testicle?hsLang=en-us)
- Closed Claim Case Study: [Failure to Close the Loop on Critical Findings Leads to Negligent Patient Death](https://www.norcal-group.com/library/failure-to-close-the-loop-on-critical-findings-leads-to-negligent-patient-death?hsLang=en-us)
- Closed Claim Case Study: [Ambiguous Radiology Report Results in Below-the-Waist Paralysis](https://www.norcal-group.com/library/ambiguous-radiology-report-results-in-below-the-waist-paralysis?hsLang=en-us)
- Best Practices: [Develop a Process for Communicating Results Based on Criticality to Improve Clinical Decision-Making](https://www.norcal-group.com/library/develop-a-process-for-communicating-results-based-on-criticality-to-improve-clinical-decision-making?hsLang=en-us)

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

- Closed Claim Case Study: [Prioritizing Urgent Diagnosis List Over Medical Judgment Leads to Patient Death](https://www.norcal-group.com/library/prioritizing-urgent-diagnosis-list-over-medical-judgment-leads-to-patient-death?hsLang=en-us)
- Closed Claim Case Study: [Failure to Directly Communicate Unexpected Cancer Finding Leads to Delayed Treatment](https://www.norcal-group.com/library/failure-to-directly-communicate-unexpected-cancer-finding-leads-to-delayed-treatment?hsLang=en-us)
- Closed Claim Case Study: [Failure to Communicate a Significant Diagnosis Change Leads to Worsened Prognosis](https://www.norcal-group.com/library/failure-to-communicate-a-significant-diagnosis-change-leads-to-worsened-prognosis?hsLang=en-us)
- Closed Claim Case Study: [Failure to Communicate a Positive Biopsy Leads to Delayed Cancer Diagnosis](https://www.norcal-group.com/library/failure-to-communicate-a-positive-biopsy-leads-to-delayed-cancer-diagnosis?hsLang=en-us)
- Best Practices: [Develop a Policy for Timely Diagnoses Communication to Facilitate Prompt Treatment](https://www.norcal-group.com/library/develop-a-policy-for-timely-diagnoses-communication-to-facilitate-prompt-treatment?hsLang=en-us)
- Best Practices: [Avoid Ambiguity in Pathology Reports to Improve Communication](https://www.norcal-group.com/library/avoid-ambiguity-in-pathology-reports-to-improve-communication?hsLang=en-us)

**Part 3: From Primary Care Physician to Patient**

- Closed Claim Case Study: [Lack of Redundancy and Coverage Contributes to Patient Death](https://www.norcal-group.com/library/lack-of-redundancy-and-coverage-contributes-to-patient-death?hsLang=en-us)
- Closed Claim Case Study: [Inadequate Follow Up on Abnormal Labs Leads to Permanent Injuries](https://www.norcal-group.com/library/inadequate-follow-up-on-abnormal-labs-leads-to-permanent-injuries?hsLang=en-us)
- Closed Claim Case Study: [Poor Test Result Communication Process Leads to Patient Injury](https://www.norcal-group.com/library/poor-test-result-communication-process-leads-to-patient-injury?hsLang=en-us)
- Closed Claim Case Study: [Failure to Convince Patient of Urgency of Follow Up Leads to Patient Death](https://www.norcal-group.com/library/failure-to-convince-patient-of-urgency-of-follow-up-leads-to-patient-death?hsLang=en-us)
- Closed Claim Case Study: [Lack of Follow Up with “No Doc” ED Patient Leads to Patient Injury](https://www.norcal-group.com/library/lack-of-follow-up-with-no-doc-ed-patient-leads-to-patient-injury?hsLang=en-us)
- Closed Claim Case Study: [Pre-Surgery Delay in Processing Abnormal Results Leads to Patient Death](https://www.norcal-group.com/library/pre-surgery-delay-in-processing-abnormal-results-leads-to-patient-death?hsLang=en-us)

## Allegation

*Failure to communicate chest x-ray findings resulted in the patient’s pneumonia going untreated and ultimately causing his death.*

## Case File

A 25-year-old man presented to the ED complaining of chest pain, difficulty breathing, and coughing. The ED physician ordered a chest x-ray. The radiologist identified a round infiltrate in the upper lobe of his left lung. His differential diagnosis was round pneumonia versus inflammatory etiology versus neoplasm. The radiologist recommended close follow-up but did not flag the report as containing a critical finding and did not contact the ED physician to report his findings.

The patient was discharged with a diagnosis of “pleuritic chest wall pain” before the ED physician reviewed the chest x-ray report. The discharge summary mistakenly indicated the chest x-ray was negative. No one contacted the patient to tell him he had pneumonia. He died a week later. Autopsy revealed bilateral empyema and pulmonary abscesses. His family filed a lawsuit against the radiologist, ED physician, and hospital.

## Discussion

The hospital critical results reporting policy was consistent with the recommendations contained in the ACR Actionable Reporting Work Group. (See “[Develop a Process for Communicating Results Based on Criticality to Improve Clinical Decision-Making](https://www.norcal-group.com/library/develop-a-process-for-communicating-results-based-on-criticality-to-improve-clinical-decision-making?hsLang=en-us)” for a discussion of these recommendations.) Pneumonia was on the list of Level 2 critical results that required communication of the findings with the referring physician “within hours.” The radiologist did not follow the critical results reporting policy. Had he done so, he most likely would have reached the ED physician before he discharged the patient with an incorrect diagnosis.

A redundant system was in place in which ED policy required culling the final x-ray reports and determining whether they were congruent with the discharge summary. Unfortunately, that procedure was not followed either. Even the best patient safety policies and procedures won’t work if clinicians and staff do not comply with them.

## Medical Liability Risk Management Recommendations

Communication process delays may result in patients being discharged from the ED with a preliminary diagnosis that is later corrected. By the time the discrepancy is discovered, the patient, ED physician, and radiologist may not be on the premises. There should be an airtight protocol for communicating these findings including contacting the patient if necessary.

Radiology and emergency departments must coordinate policies and procedures to ensure that critical findings are communicated in these circumstances. Consider the following strategies to help close potential communication gaps.*

### Emergency Department Administrators

- Standardize the method of identifying ED/radiology discrepancies and delineate an action plan for responding to them.
- Evaluate whether critical findings are being communicated to referring ED physicians by radiologists in a manner consistent with hospital policy. If they are not, address issues at an administrative level.
- Ensure that all critical results telephone communications are documented and include names of the individuals on the call, the date and time of the communication, and what was discussed.
- Ensure that discrepant results are communicated to the patient’s primary care physician or the patient. 
    - Consider dedicating a staff person to make follow-up calls to patients whose radiology or lab reports are not congruent with the initial diagnosis in the ED.

### Radiology Administrators

- Establish communication policies and procedures that identify to whom critical findings should be communicated when the ordering clinician is not available.

 

Every individual in the communication loop must fulfill their role in the process of delivering a critical result to the individual in the best position to act on it. Policies give the communication process structure. When critical results communication policies are ignored — particularly when the patient has come to the emergency department with a critical condition — the risk of patient injuries increases, as does liability risk.

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](https://www.norcal-group.com/claimsrx/part-1-communicating-critical-findings?hsLang=en-us).” This release and many others are available in the [*Claims Rx* Directory](https://www.norcal-group.com/claimsrx?hsLang=en-us) for download. Policyholders will also find instructions for obtaining CME credit for select releases.

## Reference

* American College of Radiology. [*ACR Practice Parameter for Communication of Diagnostic Imaging Findings*](https://www.acr.org/-/media/ACR/Files/Practice-Parameters/CommunicationDiag.pdf). (Resolution 11) 2014.

 Filed under: [Patient Care](https://www.norcal-group.com/library/topic/patient-care)

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