Consider these risk management recommendations for what to do and what not to do when you discover a missed finding.
Recommendations for what to do when you discover a missed finding:
- Standardize the method of identifying radiology discrepancies and adopt an action plan for responding to them.
- Document discrepancies using objective language.
- When addressing a discrepancy, choose succinct, neutral language that is non-judgmental. Avoid words and phrases such as: missed, error, mistake, overlooked, not appreciated, obviously present or should have been identified. For example, “in retrospect, the nodule in the left lower lobe was present on the radiograph of July 15, 2006,” is an appropriate way to indicate that an important finding has been overlooked.
- When the patient has been discharged following the discovery of a discrepancy, communicate the new results to the patient and/or the patient’s PCP.
- If addressing the contents of comparison reports, prepare a formal, written report for all studies that includes review of previous reports and, if indicated, comparison of previous images when possible. State if previous reports and images are not available and any attempts to obtain them.
- Utilize a quality program to track and trend the discrepancies identified.
Recommendations for what not to do when you discover a missed finding:
- Blame or disparage other clinicians or the patient in the chart.
- Offer personal (other than medical) opinions
- Speculate on causes of poor outcomes
- Make observations, notes or entries unrelated to patient care
- Make derogatory statements or use language that blames another healthcare provider (e.g., “error,” “mistake in judgment”)
- Engage in professional disputes in the report or chart
- Include references to incident reports, legal actions, and attorney or risk management activities in the medical record (these should be maintained in a separate, confidential file)
