The College of Physicians and Surgeons of Saskatchewan was recently made aware of a case where an interpreting radiologist had included potentially serious incidental findings in the body of the imaging report, but not in the summary, nor in the conclusion.  The referring physician had not read the report in its entirety, relying only on the conclusion, and therefore missed the clinical finding, leading to an unfavorable patient outcome.

Following the principles of Just Culture - a system of shared accountability in which organizations are responsible for the systems they have designed and for responding to the behaviors of their employees in a fair and just manner – the College wants to take this opportunity to appeal to physicians to work collaboratively in creating a patient-centred, safe, and responsive system for the preparation and management of imaging reports.

Physician ordering the diagnostic imaging

The ordering physician is responsible to review and follow-up the results:

• The physician who requested the imaging is responsible for the follow up and appropriate management of the result, in keeping with the College’s standards of practice, the Code of Ethics and the Code of Conduct.
• The College’s Policy “Standards for Primary Care” is clear that the CPSS expects that:

  “physicians will … provide the medical follow-up required by a patient’s condition after undertaking an examination, investigation or treatment of a patient unless the physician has ensured that another physician, another professional or another authorized person has agreed to do so.”

• The College’s Guideline “Referral – Consultation Process” also states that “the ordering physician is responsible for the follow-up of diagnostic testing” unless otherwise mutually agreed between the referring physician and consulting physician.

This brings us to factors that may have impacted on appropriate review of the radiology report in the scenario outlined above.

A CMPA article, Creating a culture of accountability highlights three types of human behaviour recognized as affecting the ability of providers to fulfill their duties in support of their organization’s mission: 

• human error,
• at-risk behaviour, and
• reckless behaviour.

In this case study, it is possible that human error or at-risk behaviour contributed to the inadequate review of the diagnostic imaging result.

In the Saegis Just Culture in Healthcare Workshop, it was highlighted that at-risk behavior includes “Behavioral drift.”  This is described as “an unconscious choice to deviate from training, stemming from a lack of perception of risk or a mistaken belief that the risk is justifiable. As providers become more comfortable with their tasks, drift is further reinforced by the fact that any resulting harm is relatively rare, thus obscuring the link between drift and potential harm.

Within a culture of accountability, it is generally recognized that behavioral drift is the single greatest threat to patient safety, owing to its unconscious nature and to its pervasiveness in everyday practice.”

Looking back to our case study, we recognize that as physicians try to cope with the ever-increasing demands of daily life and clinical practice - similar to when we review scientific literature and articles - we tend to skip over the body of the document and read only the summary or recommendation. This unfortunately may cause us to potentially miss important clinical findings.  The radiology report, like all consultations, is a conversation.  The “quality” of the conversation can be defined by the indication and pretest probability and the clarity of the response to the question.  Even if the situation is not clear as to the right course of action, the conversation provides a benefit to the medical decision process.

It is a reminder to all of us that when we request any imaging, we must review the report in detail and put the information in appropriate context. The requesting physician is responsible for patient management based on the report, unless the physician has made arrangements for another physician, another professional or another authorized person to do so.

Radiologist preparing the diagnostic imaging report

From the perspective of the radiologist reporting on the imaging, the 2000 article Language of the Radiology Report contains information that is still very relevant today. The CAR Standard for Communication of Diagnostic Imaging Findings defines the principles of practice for the purpose of communicating findings. By clearly communicating relevant findings (including incidental findings) in their reports, radiologists can significantly contribute to patient safety. If a significant abnormality is identified, radiologists should make efforts to contact the requesting physician directly.

When communicating with Dr. Sheldon Wiebe, the Provincial Head of Medical Imaging in Saskatchewan, in relation to this case study, he stated “I think we are talking about professional accountability of the referring/requesting physician as well as the radiologists in the dialogue that occurs through the request-report mechanism of communication.”  The delivery of high quality, patient-centred health care is a team endeavour; all team members, on the reporting and receiving end, have equally important roles and rely on each other to fulfil those roles.