Due to communication errors within American hospitals, many patients suffer consequences from delayed communication of critical test results and significant, unexpected findings. This issue of "fumbled communication hand-offs" was a major issue cited by the Institute of Medicine report to Congress in 1999 documenting more than 100,000 patient deaths occurring each year in the nation's hospitals and healthcare institutions due to provider errors.
This problem has reached such significant proportion that The Joint Commission's No. 2 National Patient Safety Goal for 2008 is "to improve the effectiveness of communication among caregivers," for the fifth straight year. Additionally, the American College of Radiology in 2005 re-issued its guidelines for communication and included the principles that "communication is a critical component of the art and science of medicine and is especially important in diagnostic radiology" Documentation of direct communication is recommended. In those situations [that] constitute significant unsuspected findings, the interpreting physician or his/her designee should communicate the findings to the referring physician, other healthcare provider, or an appropriate individual in a manner that reasonably insures receipt of findings."
While modern medicine provides amazing and sophisticated diagnostic imaging technology, the delivery systems for test results have not kept pace. Communication errors continue to represent a significant challenge for healthcare institutions across the enterprise. All too often, significant, unexpected findings are not relayed to the appropriate provider via traditional reporting methods. The greatest diagnostic tools mean little to the patient if his or her test findings are not communicated effectively. The healthcare industry is just now realizing the importance of this component of quality healthcare delivery, calling it Critical Test Result Management.
Case 1: A 55-year-old man presented to his internist with cough and fever on a Thursday afternoon. The doctor sent the patient across the street to the hospital for a chest x-ray. Radiographs were obtained but not read by the radiologist until Saturday morning, at which time the radiologist noted, "bilateral pneumonia, follow-up recommended." Unfortunately, the written report was not delivered to the referring doctor until the following Tuesday. The patient died the night before of Legionella pneumonia. When asked, at deposition, why he hadn't called the results to the doctor, the radiologist replied that he had tried but couldn't get through. The case was settled for an undisclosed sum, with settlements paid by the internist, the radiologist, and the local hospital.
Case 2: A 45-year-old healthcare worker went to her local hospital for a routine annual chest x-ray. The occupational health nurse ordered the examination, writing the clinic physician's name on the x-ray request. The chest x-ray revealed a 1.5-cm left upper lobe nodule, which was noted on the radiographic report as "suspicious." The results were filed in the patient's chart, but without the intended physician ever seeing the report. Three years later, the patient was diagnosed with a 4.5-cm left upper lobe lung tumor. When the old records were reviewed, it was discovered that the cancer had been noted three years earlier. In discovery depositions, it was argued that the patient had been denied the opportunity to have the tumor diagnosed and treated at a stage that "more likely than not" would have resulted in excellent outcome, if not cure. The radiologist was also faulted for not making direct contact with the clinic physician, as required by American College of Radiology standards. The case was ultimately settled for more than $2 million against both the radiologist and the local hospital (the clinic physician was an employee of the hospital).
Scope of the problem
Every radiologist has experienced cases in which the x-ray requisition had inaccurate information or the report was sent to the wrong physician. In some cases, the intended physician never gets the report and may not have a system to detect the problem. The physician who receives the report in error is under no legal obligation to do anything with it.
Watching a busy radiologist for a day is all it takes to understand the genesis of these types of communication errors. While almost all radiologists understand the need to pick up the phone and call in findings in cases of aortic injuries, brain herniations, and tension pneumothoraces, the problem becomes more complicated with non-immediate findings: a 1cm pulmonary nodule, a 2.5cm mass in the kidney, pneumonia, hairline hip fracture, or questionable lesion in a bone. These findings may be quite significant to the patient, but they are not emergent in the minds of most radiologists. And they are so common that it is simply not practical for a radiologist to call on every case.
Staff and office workers misfile reports. In other cases, reports are faxed to a fax machine that is no longer working or has run out of paper. These one-way communications are fraught with potential error. We live in a mobile society where patients and doctors move, often leaving behind a trail of incomplete medical records. In an era of managed care and employment-based insurance, many patients are disrupted from their usual sources of healthcare by job changes or employers seeking more cost-effective insurance plans. In these instances, patients may no longer be allowed to have care at one facility and are suddenly referred elsewhere within our increasingly fragmented healthcare system. These are all risk factors for fumbled hand-offs and errors in critical report communication.