​PSO Compass Points

The patient had a kidney, ureter, and bladder x-ray, and the radiologist saw no stones. The surgeon read the report, permitted the patient to eat breakfast, and recommended an appointment that afternoon. At the afternoon visit, the same surgeon reviewed the x-ray and saw stones in the patient's ureter. The surgeon had to schedule late surgery, after hours, because the patient had been given permission to eat, based on the report of no stones.

Situation

Incorrect or delayed diagnosis in radiology can result in a delay in treatment, incorrect or inappropriate treatment, or other complications.

Background

ECRI Institute PSO analyzed a sample of 231 events related to various components of the communication, prioritization of testing, and reporting of radiology tests. The event reports revealed the following:

• In 38% of events, a delay in testing and/or reporting resulted in delayed discharge
• In 29% of events, there were delays in receiving the radiologist's report
• In 14% of events, the patient had to return to the emergency department due to a misread or delayed report
• In 7% of events, a misread led to an incorrect diagnosis
• In 6% of events, the wrong limb was scanned or the wrong test was performed
• In 3% of events, there was a delay or rescheduling of surgery
• In 2% of events, there was a delay in diagnosis

Assessment

Incorrect readings and delayed diagnoses in radiology are underreported yet can pose a significant risk to patients. Increased communication and consultation between radiologists and ordering providers can provide context for the radiologist when reading the image and for the ordering provider when reviewing the radiologist's findings.

Recommendations

ECRI Institute PSO recommends the following:

• Ensure that policies and procedures to prioritize testing (e.g., inpatient vs. outpatient or ED vs. inpatient) are up to date, known, and followed.
• Implement and use a system to report critical results directly to treating providers. Track system use and feedback to ensure effectiveness and appropriateness.
• Monitor the diagnostic imaging process to identify and learn from instances of diagnostic misreads.
• Review the overall diagnostic process to ensure effective communication among providers, identification of errors, and learning.