EDs Need Process for Incidental Radiology Findings
By Stacey Kusterbeck
Sometimes, radiology tests return with abnormal “incidental” findings, but the patient has gone home. “Ensuring that patients are notified of findings that may represent an early cancer is critically important,” says Tyler W. Barrett, MD, MSCI, executive medical director of emergency services at Vanderbilt University Medical Center.
The most critical patient safety concern is that preventable progression of a cancer could have been treated sooner. “There are also potential medicolegal concerns that could accompany incidental findings that are not returned to the patient,” Barrett says.
To prevent that from happening, Vanderbilt’s ED implemented a notification and referral system for incidental radiology findings. Barrett and colleagues analyzed results for the first 13 months after the implementation.1 “Our primary motivation was patient safety,” Barrett says. “We wanted to share this highly reliable, electronic health record-integrated, critical radiology alert system and the associated incidental finding follow-up program with the emergency medicine community.”
Over 13 months, 932 ED patient visits included critical radiology alert referrals because of incidental radiology findings. In 888 of those cases, researchers confirmed communication with the patient happened and that there was a documented follow-up plan in place. In the other 44 cases, the team could not contact the patient or could not confirm follow-up.
“Either the contact information provided was incorrect, or the patient or family did not answer the phone calls,” Barrett shares. In those cases, nurses sent a certified letter to the patient’s address about the test results.
The process includes ED nurse case managers, ED social workers, and Vanderbilt Cancer Center nurse navigators. An electronic notification through Epic is sent to either the ED nurse case manager or nurse navigator, who contact the patient (typically by phone) within a few days of the visit to coordinate the follow-up plan. The notification also triggers a standard text reminder about the incidental finding in the patient’s after-visit summary. “This program’s success is the result of outstanding interdepartmental collaboration among our emergency medicine, radiology, informatics, cancer center, case management, and social worker teams,” Barrett reports.
The primary challenge was translating the radiology alert program and follow-up from the Vanderbilt-developed electronic health record system to Epic in 2017. Another challenge was educating 10 to 12 rotating off-service residents each month, and new faculty and fellows annually. “Implementing a reliable system to ensure the identification and notification of critical radiology alerts ultimately benefits emergency department patients,” Barrett concludes.
“Failure to notify” claims — in particular, cases involving inadequate follow-up on test results — “are one of the fastest growing areas of malpractice cases in the U.S.,” according to Heather L. Brown, DMSc, PA-C, DFAAPA.
In Brown’s experience, those ED malpractice claims usually involve one of two scenarios. One, radiology results were “missed” on the initial reading in the ED, but the radiologist amended the findings later. Two, lab results were entered in the chart after the patient left the ED, but no one addressed the findings. In both cases, the problem is EPs believe they have transitioned care to another person, either a primary care provider or someone else in the facility. “The EP fails to understand their continued responsibility to appropriately follow-up on all pending studies,” says Brown, owner and CEO of Roswell, GA-based HL Brown and Associates.
Somehow, the patient never learns about the test results. The mere fact the EP dictated the findings into the medical record is not sufficient for a strong legal defense. “Ensuring that the receiving individual is made aware, directly, of any abnormalities they need to take action on and documenting this communication is critical in this type of litigation,” Brown says.
To lower the risks of “failure to notify” claims, institute clear protocols on who is responsible for dealing with abnormal test results. Educate patients on how to find out about their test results; this includes obtaining updated contact information. Finally, use electronic alerts to notify patients and providers when tests results are ready.
Many times, “failure to notify” malpractice cases are rooted in an incorrect assumption. The EP assumes someone else — the ordering EP, the EP who reads the result, or the outpatient provider — will act on the abnormal results.
“Often, the central issue is that an outcome was sent to multiple individuals, but each thought the other would handle the issue,” Brown reports. “Ultimately, no action is taken.”
REFERENCE
1. Barrett TW, Garland NM, Freeman CL, et al. Catching those who fall through the cracks: Integrating a follow-up process for emergency department patients with incidental radiologic findings. Ann Emerg Med 2022 Jun 23;S0196-0644(22)00275-X.
To lower the risks of “failure to notify” claims, institute clear protocols on who is responsible for dealing with abnormal test results. Educate patients on how to find out about their test results; this includes obtaining updated contact information. Finally, use electronic alerts to notify patients and providers when tests results are ready.
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