Communication errors in radiology: a liability cost analysis

Intraoperative Communications Between Pathologists and Surgeons: Do We Understand Each Other?

CONTEXT.—

Clear communication between pathologists and surgeons during intraoperative consultations is critical for optimal patient care.

OBJECTIVE.—

To examine the concordance of intraoperative diagnoses recorded in pathology reports to surgeon-dictated operative notes and assess the impact of an intervention on the discrepancy rates.

DESIGN.—

Discrepancies between the intended communication by pathologists and the interpretation by surgeons were characterized as minor with no crucial clinical impact, and major with the potential of altering patient management. After analysis, a corrective intervention was implemented with education, information sharing, and a change in protocol, and a comparative analysis was conducted.

RESULTS.—

We examined 223 surgical cases with 578 intraoperative consultations. In 23% (51) of the cases, the intraoperative diagnosis was not recorded in the operative reports. We found minor discrepancies in 34% (59) and major discrepancies in 2% (3) of the remaining cases. Deferrals accounted for 24% (14 of 59) of the minor and 33% (1 of 3) of the major discrepancies. Among the discrepant cases, 56% (35 of 62) were multipart cases, including all major discrepancies. Following intervention, no major discrepancies were found in 101 cases with 186 intraoperative interpretations. The cases with no operative documentation reports decreased from 23% to 16% (16 of 101). Minor discrepancies were found in 11% (9 of 85) of the cases, indicating significant improvement (P < .001).

CONCLUSIONS.—

Intraoperative diagnoses can be miscommunicated and/or misinterpreted, possibly impacting intraoperative management, particularly in multipart cases and those involving deferrals. This study highlights the importance of auditing intraoperative communications and addressing the findings through a local intervention.

Factors facilitating shared decision making in eczema: Met and unmet needs from the patient perspective

Background

Research has shown that eczema patients prefer some degree of shared control over treatment decisions, but little is known about factors perceived to be important to facilitate shared decision making (SDM).

Objective

To determine factors eczema patients and caregivers consider to be important for SDM, and how often they experience them with their eczema healthcare provider (HCP).

Methods

A cross-sectional survey study (64 questions) was conducted, which included factors related to SDM rated by respondents on a Likert scale for importance, and how often these factors were true with their current eczema HCP.

Results

Respondents (840, response rate 62.4%) most frequently rated their health literacy and communication skills as important for SDM. Factors which indicated a strong provider-patient relationship, and HCPs who initiate treatment conversations were also deemed beneficial. Low importance was placed on concordant HCP race/ethnicity, however, of those who did rate it as important, 53/91 identified as Black (half of all Black respondents).

Limitations

A high proportion of respondents were aware of the term SDM prior to the survey.

Conclusions

SDM is more likely to be facilitated when patient education and empowerment are coupled with HCPs who initiate treatment discussions, maintain compassion resilience, and listen to patient perspectives.

Communication in radiology: evaluation of terminology and TNM descriptor use at a cancer center

Objective

The purpose of our study was to evaluate the transmission of information from radiologists to physicians, focusing on the level of certainty and the use of imaging descriptors from the tumor-node-metastasis (TNM) staging system.

Materials and Methods

Radiologists (n = 56) and referring physicians (n = 50) participated in this questionnaire-based, singlecenter study, conducted between March 20, 2020, and January 21, 2021. Participants were presented with terms commonly used by the radiologists at the institution and were asked to order them hierarchically in terms of the level of certainty they communicate regarding a diagnosis, using a scale ranging from 1 (most contrary to) to 10 (most favoring). They then assessed TNM system descriptors and their interpretation. Student's t-tests and the kappa statistic were used in order to compare the rankings of the terms of certainty. Items related to T and N staging were analyzed by Fisher's exact test. The confidence level was set to 97% (p < 0.03).

Results

Although overall agreement among the radiologists and referring physicians on term ranking was poor (kappa = 0.10- 0.35), the mean and median values for the two groups were similar. Most of the radiologists and referring physicians (67% and 86%, respectively) approved of the proposal to establish a standard lexicon. Such a lexicon, based on the participant responses, was developed and graphically represented. Regarding the TNM system descriptors, there were significant differences between the two groups in the reporting of lymph node numbers, of features indicating capsular rupture, and of vessel wall irregularities, as well as in the preference for clear descriptions of vascular involvement.

Conclusion

Our findings indicate that ineffective communication and differences in report interpretation between radiologists and referring physicians are still prevalent in the fields of radiology and oncology. Efforts to gain a better understanding of those impediments might improve the objectivity of reporting and the quality of care.

Handoffs in Radiology: Minimizing Communication Errors and Improving Care Transitions

Handoffs are essential to achieving safe care transitions. In radiology practice, frequent transitions of care responsibility among clinicians, radiologists, and patients occur between moments of care such as determining protocol, imaging, interpreting, and consulting. Continuity of care is maintained across these transitions with handoffs, which are the process of communicating patient information and transferring decision-making responsibility. As a leading cause of medical error, handoffs are a major communication challenge that is exceedingly common in both diagnostic and interventional radiology practice. The frequency of handoffs in radiology underscores the importance of using evidence-based strategies to improve patient safety in the radiology department. In this article, reliability science principles and handoff improvement tools are adapted to provide radiology-focused strategies at individual, team, and organizational levels with the goal of minimizing handoff errors and improving care transitions.

Quantitative Improvement in Brain Tumor MRI Through Structured Reporting (BT-RADS)

RATIONALE AND OBJECTIVES

Determine the objective benefits of structured reporting of brain tumors through Brain tumor-RADS (BT-RADS) by analyzing discrete quantifiable metrics of the reports themselves.

MATERIALS AND METHODS

Following Institutional Review Board approval, post-treatment glioma reports were acquired from two matched 3-month time periods for pre- and postimplementation of BT-RADS. The reports were analyzed for presence of history words, such as "Avastin" and "methylguanine-DNA methyltransferase," as well as hedge words, such as "Possibly" and "Likely." The word counts of the total report and of the impression section were also assessed, as well as whether or not the report contained addenda.

RESULTS

In total, 211 pre-BT-RADS and 172 post-BT-RADS reports were analyzed. Post-BT-RADS reports demonstrated greater reporting of history words, including "Avastin" (7.6% vs. 20.9%, p < 0.001) and "methylguanine-DNA methyltransferase" (10.9% vs. 31.4%, p < 0.0001). They also demonstrated reduced usage of hedge words, including "Possibly" (3.8% vs. 0.6%, p < 0.05) and "Likely" (49.8% vs. 28.5%, p < 0.01). Furthermore, post-BT-RADS reports possessed fewer words in total report length (389 vs. 245.2, p < 0.001), as well as in the impression section (53.7 vs. 42.6, p < 0.01). Finally, fewer post-BT-RADS reports contained addenda (10% vs. 1.2%, p < 0.01).

CONCLUSION

Following implementation of BT-RADS, glioma reports demonstrated greater consistency and completeness of clinical history, less ambiguity, and more conciseness.

Preimplantation and prenatal diagnosis, wrongful birth and wrongful life: a global view of bioethical and legal controversies

BACKGROUND

Prenatal diagnosis based on different technologies is increasingly used in developed countries and has become a common strategy in obstetric practice. The tests are crucial in enabling mothers to make informed decisions about the possibility of terminating pregnancy. They have generated numerous bioethical and legal controversies in the field of 'wrongful life' claims (action brought by or on behalf of a child against the mother or other people, claiming that he or she has to endure a not-worth-living existence) and 'wrongful birth' claims (action brought by the mother or parents against the physician for being burdened with an unwanted, often disabled child, which could have been avoided).

OBJECTIVE AND RATIONALE

The possibility which exists nowadays to intervene actively by programming and deciding the phases linked to procreation and birth has raised several questions worldwide. The mother's right to self-determination could be an end but whether or not this right is absolute is debatable. Freedom could, with time, act as a barrier that obstructs intrusion into other people's lives and their personal choices. Therapeutic choices may be manageable in a liberal sense, and the sanctity of life can be inflected in a secular sense. These sensitive issues and the various points of view to be considered have motivated this review.

SEARCH METHODS

Literature searches were conducted on relevant demographic, social science and medical science databases (SocINDEX, Econlit, PopLine, Medline, Embase and Current Contents) and via other sources. Searches focused on subjects related to bioethical and legal controversies in the field of preimplantation and prenatal diagnosis, wrongful birth and wrongful life. A review of the international state of law was carried out, focusing attention on the peculiar issue of wrongful life and investigating the different jurisdictional solutions of wrongful life claims in a comparative survey.

OUTCOMES

Courts around the world are generally reluctant to acknowledge wrongful life claims due to their ethical and legal implications, such as existence as an injury, the right not to be born, the nature of the harm suffered and non-existence as an alternative to a disabled life. Most countries have rejected such actions while at the same time approving those for wrongful birth. Some countries, such as France with a law passed in March 2002, have definitively excluded Wrongful Life action. Only in the Netherlands and in three states of the USA (California, Washington and New Jersey) Wrongful Life actions are allowed. In other countries, such as Belgium, legislation is unclear because, despite a first decision of the Court allowing Wrongful Life action, the case is still in progress. There is a complete lack of case law regarding wrongful conception, wrongful birth and wrongful life in a few countries, such as Estonia.

WIDER IMPLICATIONS

The themes of 'wrongful birth' and 'wrongful life' are charged with perplexing ethical dilemmas and raise delicate legal questions. These have met, in various countries and on certain occasions, with different solutions and have triggered ethical and juridical debate. The damage case scenarios result from a lack of information or diagnosis prior to the birth, which deprives the mother of the chance to terminate the pregnancy.

A comparison of medical litigation filed against obstetrics and gynecology, internal medicine, and surgery departments

Background

The aim of this study was to review the typical factors related to physician’s liability in obstetrics and gynecology departments, as compared to those in internal medicine and surgery, regarding a breach of the duty to explain.

Methods

This study involved analyzing 366 medical litigation case reports from 1990 through 2008 where the duty to explain was disputed. We examined relationships between patients, physicians, variables related to physician’s explanations, and physician’s breach of the duty to explain by comparing mean values and percentages in obstetrics and gynecology, internal medicine, and surgical departments with the t-test and χ² test.

Results

When we compared the reasons for decisions in cases where the patient won, we found that the percentage of cases in which the patient’s claim was recognized was the highest for both physician negligence, including errors of judgment and procedural mistakes, and breach of the duty to explain, in obstetrics and gynecology departments; breach of the duty to explain alone in internal medicine departments; and mistakes in medical procedures alone in surgical departments (p = 0.008). When comparing patients, the rate of death was significantly higher than that of other outcomes in precedents where a breach of the duty to explain was acknowledged (p = 0.046). The proportion of cases involving obstetrics and gynecology departments, in which care was claimed to be substandard at the time of treatment, and that were not argued as breach of a duty to explain, was significantly higher than those of other evaluated departments (p <0.001). However, internal medicine and surgical departments were very similar in this context. In obstetrics and gynecology departments, the proportion of cases in which it had been conceded that the duty to explain had been breached when seeking patient approval (or not) was significantly higher than in other departments (p = 0.002).

Conclusion

It is important for physicians working in obstetrics and gynecology departments to carefully explain the risk of death associated with any planned procedure, and to obtain genuinely informed patient consent.

An initiative to improve the management of clinically significant test results in a large health care network

BACKGROUND

The failure of providers to communicate and follow up clinically significant test results (CSTR) is an important threat to patient safety. The Massachusetts Coalition for the Prevention of Medical Errors has endorsed the creation of systems to ensure that results can be received and acknowledged.

METHODS

In 2008 a task force was convened that represented clinicians, laboratories, radiology, patient safety, risk management, and information systems in a large health care network with the goals of providing recommendations and a road map for improvement in the management of CSTR and of implementing this improvement plan during the sub-force sequent five years. In drafting its charter, the task broadened the scope from "critical" results to "clinically significant" ones; clinically significant was defined as any result that requires further clinical action to avoid morbidity or mortality, regardless of the urgency of that action.

RESULTS

The task force recommended four key areas for improvement--(1) standardization of policies and definitions, (2) robust identification of the patient's care team, (3) enhanced results management/tracking systems, and (4) centralized quality reporting and metrics. The task force faced many challenges in implementing these recommendations, including disagreements on definitions of CSTR and on who should have responsibility for CSTR, changes to established work flows, limitations of resources and of existing information systems, and definition of metrics.

CONCLUSIONS

This large-scale effort to improve the communication and follow-up of CSTR in a health care network continues with ongoing work to address implementation challenges, refine policies, prepare for a new clinical information system platform, and identify new ways to measure the extent of this important safety problem.

Frozen section diagnosis: is there discordance between what pathologists say and what surgeons hear?

OBJECTIVES

Communication in various medical settings is subject to misinterpretation. The frozen section (FS) diagnosis in patient care is dependent on successful communication between pathologists and surgeons. However, very few studies looking at FS errors analyzed postanalytic communication issues.

METHODS

A total of 300 consecutive cases, in which an FS was performed and corresponding surgical note was available, were studied. The FS diagnosis and surgeon's interpretation were recorded for all cases. Discrepancies were classified as major (clinical impact) or minor (no clinical impact).

RESULTS

We found 8 (2.7%) miscommunications, all with only minor clinical impact. These were attributed mainly to the surgeon's misinterpretation of a deferred diagnosis. Also contributing to miscommunication was the pathologist's use of nonspecific terminology such as "favor" or "scattered."

CONCLUSIONS

We found that the rate of miscommunicated FS diagnoses was low at our institution during the period of our study. However, the rate of miscommunication was similar to the much more widely recognized problem of sampling error.

Reporting guidance for oncologic 18F-FDG PET/CT imaging

The written report (or its electronic counterpart) is the primary mode of communication between the physician interpreting an imaging study and the referring physician. The content of this report not only influences patient management and clinical outcomes but also serves as legal documentation of services provided and can be used to justify medical necessity, billing accuracy, and regulatory compliance. Generating a high-quality PET/CT report is perhaps more challenging than generating a report for other imaging studies because of the complexity of this hybrid imaging modality. This article discusses the essential elements of a concise and complete oncologic (18)F-FDG PET/CT report and illustrates these elements through examples taken from routine clinical practice.

Physicians' explanatory behaviours and legal liability in decided medical malpractice litigation cases in Japan

BACKGROUND

A physician's duty to provide an adequate explanation to the patient is derived from the doctrine of informed consent and the physician's duty of disclosure. However, findings are extremely limited with respect to physicians' specific explanatory behaviours and what might be regarded as a breach of the physicians' duty to explain in an actual medical setting. This study sought to identify physicians' explanatory behaviours that may be related to the physicians' legal liability.

METHODS

We analysed legal decisions of medical malpractice cases between 1990 and 2009 in which the pivotal issue was the physician's duty to explain (366 cases). To identify factors related to the breach of the physician's duty to explain, an analysis was undertaken based on acknowledged breaches with regard to the physician's duty to explain to the patient according to court decisions. Additionally, to identify predictors of physicians' behaviours in breach of the duty to explain, logistic regression analysis was performed.

RESULTS

When the physician's explanation was given before treatment or surgery (p = 0.006), when it was relevant or specific (p = 0.000), and when the patient's consent was obtained (p = 0.002), the explanation was less likely to be deemed inadequate or a breach of the physician's duty to explain. Patient factors related to physicians' legally problematic explanations were patient age and gender. One physician factor was related to legally problematic physician explanations, namely the number of physicians involved in the patient's treatment.

CONCLUSION

These findings may be useful in improving physician-patient communication in the medical setting.

Association between physician explanatory behaviors and substandard care in adjudicated cases in Japan

Background:

When a physician provides an insufficient explanation to a patient, such as regarding diagnosis, treatment, drug use, or prognosis, the physician is deemed to have delivered substandard care. It is likely that the standards applied to physicians’ explanations have changed as a result of the increased importance of patients’ rights of self-determination. However, little or no research on decisions in medical malpractice cases has been conducted with respect to this issue.

Methods:

Based on decisions made in 366 medical malpractice cases between 1979 and 2008 focused primarily on the physician’s duty to explain relevant issues to patients, we examined the association between physicians’ explanatory behaviors and court decisions with respect to breaches of duty.

Results:

We found that physicians’ explanatory behaviors, including relevant and specific explanations provided before treatment or surgery, were important for fulfilling a physician’s duty to explain. The data also revealed that six of the 16 types of explanatory behaviors had improved during the past three decades. However, these improvements did not contribute to the fulfillment of the physician’s duty to explain.

Conclusion:

We found that there was an association between physicians’ explanatory behaviors and judicial decisions concerning substandard care, and courts were increasingly likely to consider inadequate explanatory behaviors to be a breach of the duty of care.

The perils of communicating the unexpected finding

Failure to communicate is one of the greatest problems facing radiologists today. The courts have consistently held that timely communication may be as important as the diagnosis itself. One of the major driving forces that directly affects our failure to communicate is IT. Not only does IT provide patients with up-to-date information about medical conditions and diagnoses, it also allows the public to instantly communicate with one another, something they expect physicians to do as well. The paradox is that we are so advanced in imaging technology, but not in communicating imaging findings. This article addresses some of the most pressing issues in communicating unexpected findings and their possible solutions. Information technology can be a facilitator but not the substitute for direct communication with ordering physicians.

Ethical problems in radiology: medical error and disclosure

In radiological practice, as in any medical activity, errors are inevitable despite being foreseeable and preventable. The approach to managing medical error and relations with patients prompt the need for resolving the ethical dilemma arising from conflicting legitimate interests. The solution to this dilemma is particularly complex in an environment in which the tendency to sue physicians for civil liability or incriminate them for criminal liability appears to be particularly high. The disclosure of error is undeniably useful in raising patient awareness, reducing their suffering, improving the quality of care and limiting the consequences of the damage. There does not appear to be any evidence to suggest disclosure modifies the probability of litigation against the physician.

Reducing diagnostic errors through effective communication: harnessing the power of information technology

Diagnostic errors are poorly understood despite being a frequent cause of medical errors. Recent efforts have aimed to advance the "basic science" of diagnostic error prevention by tracing errors to their most basic origins. Although a refined theory of diagnostic error prevention will take years to formulate, we focus on communication breakdown, a major contributor to diagnostic errors and an increasingly recognized preventable factor in medical mishaps. We describe a comprehensive framework that integrates the potential sources of communication breakdowns within the diagnostic process and identifies vulnerable steps in the diagnostic process where various types of communication breakdowns can precipitate error. We then discuss potential information technology-based interventions that may have efficacy in preventing one or more forms of these breakdowns. These possible intervention strategies include using new technologies to enhance communication between health providers and health systems, improve patient involvement, and facilitate management of information in the medical record.

Errors in cancer diagnosis: current understanding and future directions

PURPOSE

Errors in cancer diagnosis are likely the most harmful and expensive types of diagnostic errors. We reviewed the literature to understand the prevalence, origins, and prevention of errors in cancer diagnosis, focusing on common cancers for which early diagnosis offers clear benefit (melanoma and cancers of the breast, colon, and lung).

METHODS

We searched the Cochrane Library and PubMed from 1966 until April 2007 for publications that met our review criteria and manually searched references of key publications. Our search yielded 110 studies, of which nine were prospective studies and the remaining were retrospective studies.

RESULTS

Errors in cancer diagnosis were not uncommon in autopsy studies and were associated with significant harm and expense in malpractice claims. Literature on prevalence was scant. For each type of cancer, we classified preventable errors according to their origins in patient-physician encounters in the clinic setting, diagnostic test or procedure performance, pathologic confirmation of diagnosis, follow-up of patient or test result, or patient-related delays.

CONCLUSION

The literature reflects advanced knowledge of contributory factors and prevention for diagnostic errors related to the performance of procedures and imaging tests and emerging understanding of pathology errors. However, prospective studies are few, as are studies of diagnostic errors arising from the clinical encounter and patient follow-up. Future research should examine further the system and cognitive problems that lead to the many contributory factors we identified, and address interdisciplinary interventions to prevent errors in cancer diagnosis.

To err is human, to correct divine: the emergence of technology-based communication systems

An increasing emphasis has been placed on the importance of timely communication of imaging results, especially to the extent that clinical management decisions are modified by the information. Various methods of transmitting results have been proposed and developing technology can now be applied to helping to ensure the timely receipt of such results in a busy clinical environment. Stratifying levels of urgency, ensuring redundancy of potential recipients of such information, and the ability to assess desired benchmarks are objectives that involve many stakeholders, including radiologists, treating physicians, and institutions. An enterprise approach to this challenge, including commercially available systems, offers a potentially cost-effective solution that addresses both risk management and quality improvement goals.

Communication outcomes of critical imaging results in a computerized notification system

OBJECTIVE

Communication of abnormal test results in the outpatient setting is prone to error. Using information technology can improve communication and improve patient safety. We standardized processes and procedures in a computerized test result notification system and examined their effectiveness to reduce errors in communication of abnormal imaging results.

DESIGN

We prospectively analyzed outcomes of computerized notification of abnormal test results (alerts) that providers did not explicitly acknowledge receiving in the electronic medical record of an ambulatory multispecialty clinic.

MEASUREMENTS

In the study period, 190,799 outpatient visits occurred and 20,680 outpatient imaging tests were performed. We tracked 1,017 transmitted alerts electronically. Using a taxonomy of communication errors, we focused on alerts in which errors in acknowledgment and reception occurred. Unacknowledged alerts were identified through electronic tracking. Among these, we performed chart reviews to determine any evidence of documented response, such as ordering a follow-up test or consultation. If no response was documented, we contacted providers by telephone to determine their awareness of the test results and any follow-up action they had taken. These processes confirmed the presence or absence of alert reception.

RESULTS

Providers failed to acknowledge receipt of over one-third (368 of 1,017) of transmitted alerts. In 45 of these cases (4% of abnormal results), the imaging study was completely lost to follow-up 4 weeks after the date of study. Overall, 0.2% of outpatient imaging was lost to follow-up. The rate of lost to follow-up imaging was 0.02% per outpatient visit.

CONCLUSION

Imaging results continue to be lost to follow-up in a computerized test result notification system that alerted physicians through the electronic medical record. Although comparison data from previous studies are limited, the rate of results lost to follow-up appears to be lower than that reported in systems that do not use information technology comparable to what we evaluated.