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.
Failure to communicate chest x-ray findings resulted in the patient’s pneumonia going untreated and ultimately causing his death.
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.
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” 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.
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.*
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.
* American College of Radiology. ACR Practice Parameter for Communication of Diagnostic Imaging Findings. (Resolution 11) 2014.