'Safety net' system stops patients from falling into follow-up black hole

MIAMI BEACH, FL - A radiology report might suggest further work-up of a patient, and the referring physician is notified of such, but that information never quite makes it to the patient -- leaving behind people who receive less than optimal care. Radiologists in the Ann Arbor VA Health System in Michigan have managed to successfully bridge that gap by creating a follow-up tracking mechanism.

Nearly a million hospital deaths can be attributed to medical errors, according to a 1998 survey by the U.S. Institute of Medicine, said Dr. Vaishali Choksi in a presentation Tuesday at the 2004 American Roentgen Ray Society (ARRS) meeting.

"For radiologists, missed follow-up of a possible neoplasm is a rare event, but it's still a high-risk situation for a patient," she said, citing an incident that happened five years ago at her institution.

A patient who was scheduled for a hernia operation underwent a routine preoperative chest x-ray. An unexpected nodule was found in the right lung, and the patient was referred for follow-up. Unfortunately, his doctor did not convey that information to the patient, who returned seven months later with a larger lesion and a brain metastasis, Choksi said.

Communication failures are the most common reason that situations like the one above occur. "We may leave a message on the voicemail or communicate with a nurse at the referring physician's office, but the message is not conveyed to the physician," she said.

Rather than ignoring these unfortunate cases, Choksi's group decided to address the problem with a "forced-function" system. A diagnostic code was attached to every radiology report. The majority of cases received a "code 1," which indicated that no notification of follow-up was required. However, when a significant unexpected finding occurred, the radiologist gave the report a "code 8, possible malignancy."

This was a mandatory function of the report, so that the radiologist was obligated to code a study before the system would accept it. The appropriate referring physician was then contacted and notified, Choksi said.

A list of code 8 cases was produced on a weekly basis and passed on to the cancer registrar at the facility. The registrar was then in charge of tracking the cases and making sure that they were actually followed up. Choksi told AuntMinnie.com that the registrar did not see this additional task as a significant workload increase.

During a six-month tracking period, 17,832 imaging exams were performed at Choksi's institution. Of these, 153 were designated with a code 8. The registrar followed up on these codes 8 cases within two weeks.

In 11 instances, the registrar intervened and reminded the referring physician that additional tests were required. As a result, 40% of the code-8 cases that returned for imaging turned out to be malignancies that went on to more treatment.

And of the 11 cases that required registrar intercession, there was one that would have been completely lost to follow-up if the system had not been in place, she added.

This tracking system, which has now been fully implemented in the Ann Arbor VA system, has reduced potential patient injury. It also offers radiology an additional level of protection from a medico-legal standpoint.

"This simple system assured that significant unexpected findings received appropriate attention," Choksi wrote in her study's abstract. "An additional level of redundancy has made our environment safer for patients."

Choksi said the next step would be to gather more cases in the system and perform a root-cause analysis as to the particulars of cases that slip away. An audience member asked if the group had considered breaking down the code 8 cases by the type of exam or areas of interest. Choksi said that kind of analysis would be done in the future, but anecdotally, chest x-rays were the most common instances of cases that required registrar follow-up.

Session moderator Dr. Richard Gunderman, Ph.D., praised the safety-net system as a way to educate staff as to the importance of follow-up exams. "Too often in these situations, we point a finger and say 'Don't do that again or else.' But that's not a permanent solution to this problem."

By Shalmali Pal
AuntMinnie.com staff writer
May 5, 2004

Related Reading

Quality more important than speed in delivering bad medical news, April 16, 2004

Imaging and informed consent: What radiologists need to know to protect themselves, April 2, 2004

Patient notification letters: How to keep them hush-hush and HIPAA-compliant, April 2, 2003

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