Eliminating Errors in Follow-up of Radiology Results
Carle Foundation Hospital and Carle Clinic Association
Urbana, Illinois, USA
Team
Monica Ray, RN, BSN, Director, Foundation Quality, Carle Foundation Hospital
Napoleon Knight, MD, Vice President of Medical Affairs, Carle Foundation Hospital
Kirk Moberg, MD, PhD, Senior Vice President and Chief Medical Officer, Carle Clinic Association
Jay Yambert, MD, Department Head, Emergency Department, Carle Foundation Hospital
Joseph Barkmeier, MD, Department Head, Radiology, Carle Clinic Association
Jona Franklin, Director, Radiology, Carle Clinic Association
Allen Rinehart, RN, BSN, Manager, Emergency Department, Carle Foundation Hospital
Terri Hancock, RN, BS, Radiology Results Coordinator, Carle Foundation Hospital
Mary Jones, RN, BS, Radiology Results Coordinator, Carle Foundation Hospital
Aim
To eliminate the risk of delay in diagnosis errors by providing a review and follow-up of final radiology results from the Emergency Department (ED).
Measures
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Total radiology reports reviewed compared to the number of reports that required follow-up
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Percent of radiology reports that received follow-up for discrepancies, incidental findings or recommendations
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Exams requiring follow-up by type
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Follow-up cases involving masses with documented malignancies
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Follow-up cases involving fractures requiring a change in treatment
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Follow-up cases involving “other” findings requiring a change in treatment
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Estimated cost avoidance to institution
Changes
A root cause analysis involving a delay of diagnosis case identified the cause to be the lack of appropriate and timely follow-up on a final radiology finding. An interdisciplinary team identified and improved systems failures to eliminate this risk in future cases.
- Analyzed the current workflow to identify systems issues and deficiencies in the Emergency Department (ED) and radiology processes.
- Determined there was a need to improve the recognition of discrepancies between preliminary and final radiology readings, as well as improve the follow-up of incidental findings and Radiologist recommendations.
- Proposed a process based on advanced technology solutions for the long-term best practice to leadership from both sponsoring organizations (Carle Foundation Hospital [CFH] and Carle Clinic Association [CCA]) which was reviewed, but not approved.
- Proposed short-term solution based on a manual process which could be initiated immediately and gained approval for the program from leadership of both CFH and CCA.
- Developed a Radiology Tracking Program as a result of collaboration between Foundation Quality and Physician Leadership.
- Approved the hiring of a Radiology Results Coordinator (RC) position which was filled by a Registered Nurse (RN).
- Created a policy that defined the role of the RC.
- Created a policy for communication of significant findings.
- Approved a Medical Staff policy and addendums related to radiology results tracking and communication of significant findings and discrepancies.
- Obtained access for the RC to be able to review all necessary electronic information.
- Generated a report of all radiology orders that originated from the ED with the help of the Information Technology department. This report covered each twenty-four hour period, seven days per week.
- Developed and piloted a tracking tool to be utilized by the ED and radiologists to identify significant findings and discrepancies.
- Educated ED providers and Radiologists on the radiology tracking process.
- Piloted the Radiology Tracking Program and changed the process for efficiency and accuracy as indicated.
- Recognized that all discrepancies between ED provider readings and final interpretations by the Radiologist cannot be totally eliminated.
- Determined that the discrepancy rate was at or below the benchmark rate of 3.9 percent to 5.4 percent. Placed the emphasis on finding and following up on any discrepancy between readings by the ED provider and the Radiologist.
- Utilized the electronic medical record (EMR) to review and compare the dictated ED note and the final radiology report to identify discrepancies, incidental findings, and radiology recommendations.
- Created a tracking form to be generated by the RC when an abnormal, incidental, unusual, or discrepant finding was identified as well as any recommendation made by the Radiologist in the final interpretation of the radiology exam.
- Modified the path of communication between the Radiologists and ED providers, by utilizing the RC when necessary.
- Established a notification process to the patient and/or their primary care providers (PCPs) when radiology findings necessitated a tracking form and follow-up.
- Created a spreadsheet document for tracking purposes for short- and long-term use.
- Initiated a thirty day tracking process on any radiology finding that had received follow-up by the RC to determine documentation, and/or change in treatment if made by the PCP, and the resulting diagnosis.
- Developed a process to track cases that required long-term follow-up to reach diagnosis for completion of data collection.
- Developed a protocol for completion of cases in the tracking program, when diagnosis is determined, or undetermined, based on the criteria.
- Modified and standardized the program to promote efficiency and usability.
- Reported monthly data to the Radiology Tracking Program Oversight Committee, the Clinical Improvement Committee, as well as Leadership and Governing Boards of the sponsoring organizations.
- Recognized the positive results of the tracking program that indicated improved patient care and risk reduction for delay in diagnosis errors, and considered expansion of the program.
- Proposed a Radiology Tracking Program to extend to the inpatient population based on the success of the ED program, and gained approval from organizational leadership (CFH and CCA).
- Hired and initiated training of additional RC staff to be able to expand the program.
Summary of Results / Lessons Learned / Next Steps
This initiative established a process for ensuring appropriate and timely follow-up on all radiology interpretation discrepancies and incidental findings, which had not existed before. The initiative has effectively eliminated the risk of missed diagnosis or delay in diagnosis of radiology findings on exams ordered from the ED. The initiative results have met the goal and have been sustained for over two years.
Lessons Learned:
- Resolving the differences of opinion related to role, responsibility, and accountability of the individual physician versus systems solutions must be accomplished for the good of the sponsoring organizations.
- Convincing all leadership and providers of the clinical and financial benefit of the program is imperative, with the emphasis on improved patient care.
- Creating short-term, immediate solutions can work with complex manual processes, and with computer systems that do not interface.
- Utilizing experienced nurses to review ED generated radiology reports results in improved follow-up of findings.
- Managing the volume of radiology reports generated from the ED is challenging and quite time consuming, so utilization of resources must be refined, making it as streamlined as possible.
- Savings from cost avoidance and a reduced liability risk will more than offset the cost of staffing, equipment, and supplies.
- Establishing good relations between the ED, Radiology, Results Coordinators, and Primary Care Providers can improve the success rate of this program.
- Improving provider compliance with patient follow-up and documentation can be made with a tracking program.
- Communicating patient outcomes to the providers reinforces and facilitates compliance.
- Making the process a win-win situation for the patient also makes a win-win situation for the organization.
Contact Information
Terri Hancock, RN, BS, Radiology Results Coordinator
Carle Foundation Hospital
Terri.Hancock@Carle.com
[Storyboard presentation at IHI's National Forum, December 2005]
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