The American College of Radiology has recognized that radiologists have a responsibility not only to accurately interpret the various radiological studies, but they also have a duty to properly communicate those findings. Ineffective communication, a major cause of medical errors, has been cited as one of the major causes of medical malpractice.
Since 1991 the American College of Radiology has adopted guidelines for communication of diagnostic imaging findings. The current version of the guidelines recognizes two distinct, yet equally important, methods of communication. The first method is the requirement to issue a final report which becomes part of the patient's chart and is archived along with the images it refers to for future reference. While the final report is required in every instance, the issuance of a final report does not satisfy the radiologist's duty to effectively communicate findings to the ordering physician. There are instances which recognize the need to immediately communicate certain findings either by direct verbal communication or electronic communication. The American College of Radiology refers to these as preliminary reports which are separate and distinct from the final report.
Final reports are communicated through the usual channels established by hospitals or diagnostic imaging facilities. There are however, recognized emergent or non-routine clinical situations which require the radiologist to expedite the delivery of the imaging report in a manner that reasonably ensures timely receipt of the findings. The American College does categorize situations in which non-routine communications are required including findings that suggest a need for immediate or urgent intervention; findings that are different than a preceding interpretation of the same examination and where failure to act may adversely affect the patient's health; and situations where the findings may be unexpected by the treating or referring physician and may result in serious adverse consequences to the patient's health. What the guidelines lack is identification of the specific instances in which a direct verbal communication is necessary. The American College recommends that the imaging department's policy on communication provide guidance on the type of communications that are most critical and the methods of communications which are most appropriate. The Joint Commission on Accreditation of Health Care Organizations (JCAHO) has similar standards which require hospitals to identify under what circumstances radiology findings are to be reported urgently to a patient's medical providers. This is where the current system begins to falter.
Many hospitals are currently operating without any such lists of situations which give rise to critical findings. Some institutions will have these situations itemized in their protocols but often fail to make these policies known to its staff. This allows each individual radiologist to set their own standards as to what is a critical finding and when the results need to be urgently communicated.
Such was the case involving a 54-year-old man whose primary care physician ordered a standard chest x-ray for a suspected case of bronchitis. The x-ray revealed suspicious lesions in his lung. Following standard protocol, the patient was given a CT scan of the chest which was interpreted and reported as consistent with multiple masses in the lung suspicious for cancer and recommended a biopsy. The biopsy confirmed the presence of non-Hodgkin's lymphoma and the patient was referred to an oncologist. As part of the staging process, the oncologist ordered a PET/CT scan, a pelvic CT and an abdominal CT.
Two days after the PET/CT scan was performed, the patient was seen in the emergency room of the local hospital with complaints of severe upper back pain, graded by him as 10 out of 10 on the pain scale, and a feeling of numbness which started in his toes and progressed to his knees and then to his waist. His medical history of recently diagnosed non-Hodgkin's lymphoma and the various PET/CT scans was also given by the patient. The emergency room physician performed a neurological exam but found no objective signs to explain the pain and numbness. A call was placed to the treating oncologist which resulted in the oncologist requesting that the patient be sent directly to his office where he would obtain the results of the PET/CT scan and discuss the findings with the patient. The oncologist contacted the radiology department of the hospital asking for the results of the PET/CT scan but was told it had not yet been reported upon.
After performing his own neurological exam, which did not reveal the source of the patient's pain and numbness, the oncologist telephoned the patient's primary care physician and made arrangements for the patient to be immediately seen at his office. Again, a neurological exam was performed without identifying the source of the problems the patient was encountering. The patient was then sent home. The oncologist made a second call to the hospital again asking for the results of the PET/CT scan and was advised again, that the report was not finalized.
After resting at home in bed, the patient became aware that he had totally lost the ability to move his lower limbs. He was urgently taken back to the hospital and the PET/CT final report was electronically signed by the radiologist at 11:59 p.m. The report indicated that there was a destructive lesion at T5 with extension into the spinal canal.
At the trial, the oncologist testified that if he had been made aware of that finding when the patient was at his office, he would have immediately recognized that the patient had a spinal tumor in the area of the thoracic spine which was impinging upon the spinal cord. This, according to the oncologist, presented an emergency situation requiring surgical removal of the tumor before irreversible damage occurred to the spinal cord. The medical records revealed that the radiologist had in fact reviewed the PET/CT images at 1:31 p.m. and had completed her dictated report by 1:45 p.m. She testified that she was unaware of any hospital policies which respect to communicating critical findings and that in her opinion, her findings were not new findings or in any way presented an emergency situation requiring prompt verbal communication; therefore, she followed her normal routine practice of only issuing a final report to normal channels, which was not received by the oncologist until the morning after the patient was readmitted to the hospital. The basis for her position was that when she compared the PET/CT images and her report with the chest CT scan performed 10 days earlier, there was virtually no change in the patient's condition. Thus, she believed that the patient's status was stable.
The problem with this conclusion was that the earlier CT report did not in any way describe the tumor being wrapped around the spine or invading the vertebrae or extending into the spinal canal.
Virtually all doctors who order tests for their patients would acknowledge that under these circumstances, they would have expected the radiologist to put down the dictating equipment, pick up the telephone, and immediately communicate what she was seeing on the images to the ordering physician. While this would be a matter of common sense to patients, it was argued to be a discretionary matter since there were no specific rules, regulations, guidelines or protocols governing her actions.
As demonstrated in the above case, without practice wide radiological standards defining what constitutes a critical finding and when the results need to be urgently communicated, the margin for discretionary error can result in negligent care provided to patients. In today's society, where technology seemingly has the ability to connect individuals effortlessly and instantaneously, the failure to have a simple system of communication to prevent such irreversible error is inexcusable.
Since the firm's founding in 1987, the injury attorneys at Powers & Santola, LLP, have established a reputation for excellence by devoting all of our attention to very seriously injured clients. Our goal in every case we take is to achieve the maximum financial recovery our client is entitled to receive.
Website: http://www.powers-santola.com
Contact Information: Adam Powers
Powers & Santola, LLP
Albany, New York
United States
Voice: 518-290-1562
http://www.powers-santola.com/
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