Summary
Learn more about the importance of communicating incidental findings.
Coverys closed claims data from 2019-2023 show that events involving incidental findings often result in high-indemnity payments, with 76% of those events resulting in death or high-severity injury. Many of these claims, like the one that follows, arise from the practitioner’s failure to adequately communicate the incidental finding and the need for further investigation with the person responsible for follow-up.
The patient, a former smoker with a 28 pack-year history, presented to an orthopedic surgeon for evaluation of her right knee pain. The surgeon recommended a total knee replacement due to degenerative joint disease and ordered a preoperative chest X-ray (CXR). He also asked the patient’s primary care provider (PCP) to perform a preoperative medical evaluation and told the PCP of the CXR order.
The CXR and laboratory work were performed at the hospital. The radiologist’s CXR interpretation included a questionable 3cm density beneath the right first rib. His report noted that finding and recommended a follow-up CT scan or additional X-ray views. He did not call the PCP or the orthopedic surgeon to relay the finding and discuss follow-up. He did, however, send a copy of his report to the orthopedic surgeon’s office, and it was entered into the hospital’s electronic health record (EHR). The PCP had no access to the hospital’s EHR platform and was not copied on the radiologist’s report. The patient was never informed of the incidental finding nor of the need for follow-up.
Two years later, the patient was diagnosed with lung cancer. When previous films were reviewed, the mass that had been identified in the preoperative CXR was noted to have grown significantly. The patient later died from lung cancer.
The defendant radiologist explained that a “density” is a very nonspecific term and can represent a variety of lung pathologies, the majority of which are benign. He had not been overly concerned with the finding of a density, nor had he believed it to represent cancer or another condition that would cause serious adverse health risks to the patient. He explained that he would not describe the density as being an “unexpected” or “critical” finding. However, its identification meant the study had not been “normal,” which was why he had recommended additional imaging studies.
Under the circumstances, the radiologist felt that the standard of care had not required him to directly contact the referring physician to relay the discovery of a density on the CXR. He thought direct contact with the ordering physician was generally reserved for findings that may cause death or immediate harm to the patient.
The defendant orthopedic surgeon who had performed the surgery acknowledged in deposition that he had received the radiology report but had not read it. He testified that he had expected the radiologist to call him with the incidental finding. The surgeon also testified that even though he had ordered the CXR, because the PCP had been responsible for medically clearing the patient for surgery, the PCP should have read the report and followed up on the incidental finding.
The defendant PCP testified that he had not been certain what the orthopedic surgeon wanted by way of preoperative evaluation but acknowledged that he had never contacted the surgeon for clarification. The PCP had documented his preoperative examination but had not documented acknowledging the results of the CXR and laboratory work that had been performed at the hospital. While the PCP was not sure if the hospital had a requirement for preoperative chest X rays, he believed that surgeons often order them unnecessarily. The PCP admitted that he had signed the preoperative evaluation form unaware of the results of the CXR, urinalysis, and metabolic panel. He had, however, reviewed the results of the EKG that had been performed at his office.
The expert witnesses agreed that American College of Radiology guidelines require direct communication when the interpreting physician discovers an unexpected finding that may seriously impact a patient’s health but may not require immediate attention. In this case, even though the 3cm density did not require immediate attention, it did require follow-up. Because the finding could have seriously affected the patient’s health, direct communication was required. This held true even if the finding were not a cancerous mass but was instead, for example, pneumonia or residual tuberculosis. The risk of missing a potentially serious finding outweighs the potential of false negatives or the extra effort it takes to communicate with the ordering physician.
Consider these factors when analyzing the process your organization uses to follow up on incidental findings:
This case was settled out of court.
*The case study referenced in this article is derived from Coverys closed cases. Identifying details have been removed or altered to protect the anonymity of patients, families, practitioners, and healthcare organizations. Any patient information, including Protected Health Information (as defined by Health Insurance Portability and Accountability Act) that could potentially identify the patient has been de-identified, removed, or restricted to a limited data set.
Copyrighted. No legal or medical advice intended. This post includes general risk management guidelines. Such materials are for informational purposes only and may not reflect the most current legal or medical developments. These informational materials are not intended, and must not be taken, as legal or medical advice on any particular set of facts or circumstances.
Facts:
The patient, a former smoker with a 28 pack-year history, presented to an orthopedic surgeon for evaluation of her right knee pain. The surgeon recommended a total knee replacement due to degenerative joint disease and ordered a preoperative chest X-ray (CXR). He also asked the patient’s primary care provider (PCP) to perform a preoperative medical evaluation and told the PCP of the CXR order.
The CXR and laboratory work were performed at the hospital. The radiologist’s CXR interpretation included a questionable 3cm density beneath the right first rib. His report noted that finding and recommended a follow-up CT scan or additional X-ray views. He did not call the PCP or the orthopedic surgeon to relay the finding and discuss follow-up. He did, however, send a copy of his report to the orthopedic surgeon’s office, and it was entered into the hospital’s electronic health record (EHR). The PCP had no access to the hospital’s EHR platform and was not copied on the radiologist’s report. The patient was never informed of the incidental finding nor of the need for follow-up.
Two years later, the patient was diagnosed with lung cancer. When previous films were reviewed, the mass that had been identified in the preoperative CXR was noted to have grown significantly. The patient later died from lung cancer.
Testimony:
The defendant radiologist explained that a “density” is a very nonspecific term and can represent a variety of lung pathologies, the majority of which are benign. He had not been overly concerned with the finding of a density, nor had he believed it to represent cancer or another condition that would cause serious adverse health risks to the patient. He explained that he would not describe the density as being an “unexpected” or “critical” finding. However, its identification meant the study had not been “normal,” which was why he had recommended additional imaging studies.
Under the circumstances, the radiologist felt that the standard of care had not required him to directly contact the referring physician to relay the discovery of a density on the CXR. He thought direct contact with the ordering physician was generally reserved for findings that may cause death or immediate harm to the patient.
The defendant orthopedic surgeon who had performed the surgery acknowledged in deposition that he had received the radiology report but had not read it. He testified that he had expected the radiologist to call him with the incidental finding. The surgeon also testified that even though he had ordered the CXR, because the PCP had been responsible for medically clearing the patient for surgery, the PCP should have read the report and followed up on the incidental finding.
The defendant PCP testified that he had not been certain what the orthopedic surgeon wanted by way of preoperative evaluation but acknowledged that he had never contacted the surgeon for clarification. The PCP had documented his preoperative examination but had not documented acknowledging the results of the CXR and laboratory work that had been performed at the hospital. While the PCP was not sure if the hospital had a requirement for preoperative chest X rays, he believed that surgeons often order them unnecessarily. The PCP admitted that he had signed the preoperative evaluation form unaware of the results of the CXR, urinalysis, and metabolic panel. He had, however, reviewed the results of the EKG that had been performed at his office.
The expert witnesses agreed that American College of Radiology guidelines require direct communication when the interpreting physician discovers an unexpected finding that may seriously impact a patient’s health but may not require immediate attention. In this case, even though the 3cm density did not require immediate attention, it did require follow-up. Because the finding could have seriously affected the patient’s health, direct communication was required. This held true even if the finding were not a cancerous mass but was instead, for example, pneumonia or residual tuberculosis. The risk of missing a potentially serious finding outweighs the potential of false negatives or the extra effort it takes to communicate with the ordering physician.
Risk Recommendations:
Consider these factors when analyzing the process your organization uses to follow up on incidental findings:
- Don’t make assumptions. Diffusion of responsibility occurs when practitioners don’t act because they assume that someone else will. Simply because someone “should” act or would “typically” follow up doesn’t mean that they will. Upon discovering an incidental finding, follow up immediately by direct communication with referring or treating practitioners until you have confirmation that they understand the significance of the finding and the need for follow-up.
- Pick up the phone. Report routine radiology results through the normal communication channels established by the organization. Deliver nonroutine results —those that may seriously impact the patient’s health or worsen over time if not acted upon—by non-routine communication. Nonroutine communication includes direct communication in person or by telephone, text, facsimile, voice message, or any other method that is likely to capture the attention of the treating or referring practitioner. Without direct communication, it may be difficult to confirm receipt and/or accurate interpretation.
- Don’t use jargon. Traditionally, radiology reports were written for referring or treating physicians. Today, patients with varying degrees of health literacy can access these reports via the patient portal. The use of technical jargon and complex terms in radiology reports can make comprehension difficult not only for patients but for referring/treating clinicians as well. Use concise, nontechnical language and illustrations to convey findings and follow-up recommendations.
- Redesign reports. Important information about findings and follow-up recommendations can get lost in the body of a textually dense, complex radiology report. Highlight important findings and specific follow-up recommendations by writing them in bold type, placing them in a labelled box, and positioning the box at the top of the report so that it is hard to miss.
- Notify the patient. Don’t forget that the patient is an important member of the treatment team. Notify the patient about significant findings as well as expected follow-up. Don’t assume another clinician will notify the patient. Consider including a “patient friendly” summary of findings written in plain langua ge in each report.
- Document. Be sure to document all conversations you have with patients and referring or treating practitioners regarding findings and recommended follow-up. Include in this documentation the information you relayed to them as well as their understanding of that information and agreement to follow up on those findings.
This case was settled out of court.
*The case study referenced in this article is derived from Coverys closed cases. Identifying details have been removed or altered to protect the anonymity of patients, families, practitioners, and healthcare organizations. Any patient information, including Protected Health Information (as defined by Health Insurance Portability and Accountability Act) that could potentially identify the patient has been de-identified, removed, or restricted to a limited data set.
Copyrighted. No legal or medical advice intended. This post includes general risk management guidelines. Such materials are for informational purposes only and may not reflect the most current legal or medical developments. These informational materials are not intended, and must not be taken, as legal or medical advice on any particular set of facts or circumstances.