Healthcare Communication: Case Studies and Best Practices for Communicating Critical Findings

Communication failure — especially failure to communicate critical findings in a timely manner — can cause patient injury due to treatment delay, delayed diagnosis or misdiagnosis, or lack of follow-up, and is a frequent allegation in malpractice lawsuits. Especially in primary care practices, expedited follow-up on critical or significantly abnormal test results is a major aspect of liability risk management and patient safety.

While these communication failures can happen anywhere along the continuum of care, the case studies and articles linked below focus on several critical transition points: from radiology to emergency department (ED), from anatomic pathologist to ordering and primary care physician, and from primary care physician to patient. Though the recommendations are directed at common specialties involved in communicating critical findings, many of the recommendations have applicability to healthcare professionals and practices generally.

Part 1: From Radiology to ED

To ensure timely delivery of critical radiology findings to referring ED clinicians, everyone involved must consider the entire communication loop. The process starts when the ED clinician orders an imaging examination and continues when radiology personnel create the images. The next piece is the communication of the results. The conclusion of the process occurs when the referring ED clinician receives and confirms receipt of the findings.¹ A break at any point in the communication loop can result in communication delay, diagnosis delay, patient injury, and the filing of a lawsuit.

Judging from malpractice plaintiffs’ allegations and referring physicians’ testimony in NORCAL closed claims, there is an expectation that radiologists will directly communicate critical findings to the referring ED physicians in a timely manner. This apparent focus on radiologists as the party responsible for pushing critical results out (as opposed to the ED physician being responsible for pulling the results in) is apparent in the Joint Commission’s National Patient Safety Goals for the Hospital Program (Goal 2, NPSG.02.03.01) and in the American College of Radiology’s Practice Guideline for Communication of Diagnostic Imaging Findings. This is not to say that diligence and hard work by radiologists will guarantee timely treatment of a critical condition, or that no one else shares in the responsibility of timely critical results communication. As the case studies below demonstrate, everyone in the communication loop can contribute to the success or failure of critical results reporting.

While radiologists and ED physicians have differing opinions about communication responsibilities, radiologists can increase patient safety and decrease liability risk with timely, direct reporting of critical results to referring ED physicians, even when the results are available in the EHR. Redundancy in communication systems increases patient safety and reduces malpractice liability risk. It is worth the extra effort.

The case studies and articles linked below focus on radiologist and radiology department/group administrator strategies for timely reporting of critical results to referring ED clinicians, but any individual involved in the critical result communication loop between the radiology and emergency departments can use the critical result communication strategies presented to increase patient safety and reduce liability risk exposure.

Part 2: From Anatomic Pathologist to Ordering and Primary Care Physician

Considering that the processes required in anatomic pathology diagnosis often take hours or even days, the concept of critical results reporting requires an adjustment of terminology and analysis.^2,3,4 For example, “critical” in clinical pathology, radiology, and other medical specialties is generally associated with a life-threatening condition that requires communication within minutes.⁵ However, few pathological diagnoses require immediate communication to the ordering physician.^2,5 Most pathological diagnoses might be better described as “actionable, noncritical results.”² Consequently, for a pathologist, effectively communicating a diagnosis to the person in the best position to use it for the patient’s benefit is usually more important than expediency.⁵

This is not to say that there aren’t circumstances in which an anatomical pathology diagnosis should be immediately communicated. It is generally agreed upon that immediate communication is necessary when a delay may harm the patient. For example, a pathologist should immediately contact the ordering physician when they diagnose transplant rejection. But there is significant disagreement among pathologists — and even more disagreement among pathologists and ordering clinicians — regarding which diagnoses require a STAT telephone call.^3,4

Treatment delay caused by a communication failure between a pathologist and ordering or primary care physician is a frequent allegation in malpractice lawsuits against pathologists. Because of disagreement over which diagnoses require immediate and direct communication, experts and defendants frequently have strong differences of opinion regarding the standard of care for communicating these diagnoses. These case studies and articles provide strategies for communicating urgent, unexpected, and actionable anatomic pathology diagnoses.

Part 3: From Primary Care Physician to Patient

Primary care physicians (PCPs) receive a considerable number of test results.⁶ One study found that a typical PCP reviews an average of 930 pieces of chemistry/hematology data and 60 pathology/radiology reports per week.⁷ Volume is not the only reason test result management and follow-up is complex.⁸ It requires multi-step data sharing among multiple physicians, staff, and patients across a variety of settings using different manual and electronic systems.^9,10 Lurking among the voluminous test results moving through various complex systems are critical and significantly abnormal findings that require expedited follow-up. These test results may be overlooked, misunderstood, or misdirected at any step along the way⁶ and delays and failures can be deadly.^8,9

One aspect of managing the risks associated with significantly abnormal test result management and communication is anticipating potential errors and instituting processes that make them less likely. The following case studies based on NORCAL closed claims show the variety of ways significantly abnormal test result follow-up failures can result in patient harm and lawsuits against physicians. Risk management strategies are provided to help PCPs, staff, and administrators recognize and correct error-prone practices.

Do You Have an Effective “Tickler System”?

Evidence of absent or poor follow-up systems can be used to support negligence allegations and to shed a generally negative light on the defendant physician during malpractice litigation. There are a variety of ways to ensure that patients receive test results in a timely fashion. Consider the following recommendations:¹¹

• Utilize the tracking and follow-up capabilities in an electronic medical record system to their full capabilities.
• Ask the laboratory/radiologist/pathologist how long it will take to provide results and use this time frame when developing a follow-up system.
• When ordering tests, tell patients approximately how long it will take to obtain results and advise them to call by an appropriate date if they have not been advised of the results.
  • Requesting the patient’s involvement in follow-up should enhance, not replace, an office “tickler system.”
• For manual tracking, consider implementing the following:
  • Place copies of all ordered tests in a designated file.
  • Monitor this file regularly to ensure that all ordered tests have been completed and that you have received the results.
• Contact patients, consultants, and the facility conducting the test (as appropriate) to determine the reason for delayed tests or missing test results.
• Utilize a tracking mechanism to compare all tests ordered with the corresponding results.
• Document follow-up communication in the medical record.
• Audit communication processes to ensure compliance with reporting procedures and the timeliness of abnormal test result follow-up.
  
  

Responsibility for Co-Managed Patients

In most circumstances, PCPs should take responsibility for follow-up on tests they have ordered. But PCPs often receive results from tests that have been ordered by other physicians. Determining responsibility for follow-up on results when a patient is receiving treatment from multiple physicians can be complicated.^9,12

A key to appropriate follow-up with patients who are co-managed by multiple physicians is establishing which physician is responsible for follow-up.¹² A common scenario in claims against NORCAL-insured PCPs often starts with a patient presenting to the ED. While there, the ED physician orders a variety of studies. In one of the studies there is an incidental finding of potential cancer. The specialist sends this report to the PCP and other specialists on the patient’s healthcare team. Each physician assumes someone else will follow up on the incidental finding but no one does and the patient never learns about it. Months or years later, the patient is diagnosed with cancer, but by that time the cancer has grown or metastasized and the patient’s chance of survival is diminished.

The defense of these claims against PCPs can be complicated, because in most cases the PCP has reviewed the report. During litigation, experts will often disagree about who among the patient’s healthcare team members had primary responsibility for following up with the patient. But all agree that someone should have communicated the results to the patient. A common outcome is all defendants contributing to a settlement.

References

1. David L. Weiss, et al. “Radiology Reporting: A Closed-Loop Cycle from Order Entry to Results Communication.” Reference Guide in Information Technology for the Practicing Radiologist. 2013. DOI: 10.1016/j.jacr.2014.09.009

2. Lester J. Layfield. “Critical Values: Has Their Time Arrived for Cytopathology?” Cancer Cytopathology. 2014;122(3): 163-166. DOI: 10.1002/cncy.21378

3. Jonathan R. Genzen, Christopher A. Tormey. “Pathology Consultation on Reporting of Critical Values.” American Journal of Clinical Pathology. 2011;135(4):505-513. DOI: 10.1309/AJCP9IZT7BMBCJRS

4. Christopher N. Chapman, Christopher N. Otis. “From Critical Values to Critical Diagnoses: A review with an Emphasis on Cytopathology.” Cancer Cytopathology. 2011;119(3):148–57 DOI: 10.1002/cncy.20158

5. Raouf E. Nakhleh, Jeffrey L Myers, et al. “Consensus Statement on Effective Communication of Urgent Diagnoses and Significant, Unexpected Diagnoses in Surgical Pathology and Cytopathology from the College of American Pathologists and Association of Directors of Anatomic and Surgical Pathology.” Archives of Pathology & Laboratory Medicine. 2012;136(2):148-154. DOI: 10.5858/arpa.2011-0400-SA

6. John U. Young. “Failure to Communicate Clinical Test Results - A Legal Analysis for Pennsylvania.” Center for Health Law, Policy & Practice. Policy Brief. 2011, citing, Eric G. Poon, Samuel J. Wang, et al. “Design and Implementation of a Comprehensive Outpatient Results Manager.” Journal of Biomedical Informatics. 2003;36:80-91. DOI: 10.1016/S1532-0464(03)00061-3

7. Eric G. Poon, Samuel J. Wang, et al. “Design and Implementation of a Comprehensive Outpatient Results Manager.” Journal of Biomedical Informatics. 2003;36:80-91. DOI: 10.1016/S1532-0464(03)00061-3

8. Angelica Montes, Michelle Francis, et al. “Assessing the Delivery of Patient Critical Laboratory Results to Primary Care Providers.” Clinical Laboratory Science. Summer;27(3):139-42.

9. Joanne Callen, Andrew Georgiou, et al. “The Impact for Patient Outcomes of Failure to Follow Up on Test Results. How Can We Do Better?” Journal of the International Federation of Clinical Chemistry and Laboratory Medicine. 2015 Jan; 26(1): 38–46.

10. Joanne L. Callen, Johanna I. Westbrook, et al. “Failure to Follow-Up Test Results for Ambulatory Patients: A Systematic Review.” Journal of General Internal Medicine. 2012;27(10):1334-1348. DOI: 10.1007/s11606-011-1949-5

11. Hardeep Singh, Meena S. Vij. “Eight Recommendations for Policies for Communicating Abnormal Test Results.” Joint Commission Journal on Quality and Patient Safety. 2010 May;36(5):226-232. DOI: 10.1016/S1553-7250(10)36037-5

12. Kevin B. O’Reilly. “Flood of Test Results Prompts New Attention on How to Manage Flow.” American Medical News. 5/24/2010.