Otolaryngology: Reduce Risk When Performing Diagnostic Imaging Services

Medical care has become increasingly specialized, and technology is driving subspecialization. Diagnostic imaging is a perfect example. Imaging procedures that were once solely performed and interpreted by radiologists are moving into other disciplines. It is common for advanced subspecialties, such as otolaryngology, to include performance and interpretation of screening and diagnostic imaging studies within their scope of practice.

Today’s otolaryngologists are prepared to incorporate imaging into their practices. The Accreditation Council for Graduate Medical Education (ACGME) requires the inclusion of education on imaging studies of the head and neck in its accredited otolaryngology residency programs. Head and neck imaging studies are also a component of the scope of knowledge for board certification.

Both the American Medical Association and the Centers for Medicare and Medicaid Services have expressed support for the transition to point-of-care imaging by trained practitioners regardless of their medical specialty.

The following risk and patient safety considerations are for practices that have or intend to incorporate point-of-care diagnostic imaging services.

Verify Credentials and Competence

It is necessary to ensure the appropriate education, training, and competence before permitting a physician to participate in diagnostic imaging procedures. This involves verifying graduation from an accredited medical school, completion of an ACGME residency program, and board certification with the original organization conferring the achievement. This is known as primary source verification. Competency is usually measured by completion of a prescribed number of supervised procedures followed by additional unsupervised procedures.

Specialty societies are a good source of guidance for both baseline preparation and ongoing competency criteria. Criteria may include specific education requirements, mandatory procedure performance volume, phantom testing, peer review, and overreads. For example, the American Academy of Otolaryngology–Head and Neck Surgery provides information on the performance of CT and cone beam CT (CBCT), the American Institute of Ultrasound in Medicine (AIUM) provides training guidelines for ultrasound, and the American College of Radiology (ACR) provides a practice parameter for ultrasound.

Seek Accreditation for Each Modality

Specialty accreditation by service line indicates that minimum standards for practitioner preparation and competence have been met, as well as criteria for administrative requirements, equipment performance, and quality and patient safety standards. Accrediting bodies in head and neck imaging include the Intersocietal Accreditation Commission, AIUM, and ACR.

Use Structured Reporting

Structured reports are templated to improve consistency, readability, and clarity, which facilitates comprehensiveness. The Radiological Society of North America (RSNA) supports structured reporting and provides freely distributed structured reporting templates. Structured reporting is effective in improving communication, the failure of which can be a cause of medical errors.¹ Structured reporting works best when the structure is developed collaboratively with those reporting and receiving the reports.

Communicate Report Findings

Diagnostic imaging interpretation is a high-risk practice that contributes significantly to diagnostic error and patient harm. Good communication is essential. Develop a system to identify and address all reports: preliminary, final, and amended. When report content is revised in such a way that decision making and patient care may be affected, timely synchronous communication with the referring provider is recommended.

Address Incidental Findings

An incidental finding is an actionable abnormality that is not related to the disease or symptoms that prompted the study. Incidental findings are common; one study suggested that over half of all imaging scans contain at least one incidental finding. These findings are confounding to practitioners and can result in a “cascade” of services and testing when pursued.² 

On the other hand, failure to address incidental findings is a common component of medical malpractice claims, largely due to lack of follow-up. Addressing incidental findings is a balancing act. CBCT is a good example. An incidental CBCT finding in otolaryngology may be a diagnostic finding in dentistry and vice versa.

In The Doctors Company study, Detecting and Addressing Incidental Findings: Medical Malpractice Claims, incidental findings were identified as a contributing factor potentially leading to patient harm that could result in a malpractice claim. Also analyzed were instances of no follow up by the practitioner in charge of the patient’s care.

In addition to applying skill and judgment, practitioners who encounter incidental findings must apply critical thinking to determine whether the incidental finding is significant, whether it should be reported to the patient, and whether follow-up action is needed. The decision should be documented in the report. If follow-up is recommended, referring practitioners appreciate guidance on next steps. Specify the type and timing of additional testing and/or the recommended referral. Do not bury the guidance in the body of the report—include important incidental findings in the summary and recommendations.

Implement Communication Strategies

We know that if an adverse event occurs, an angry patient is more likely to pursue a claim. A review of otolaryngology claims closed by The Doctors Company between 2010 and 2023 indicates patient dissatisfaction with care causing them to seek other providers was a significant contributing factor, followed by patient nonadherence with the treatment plan or follow-up.

While some patient issues may be related to personality, it is likely that health literacy challenges are a significant factor. Implementing simple patient communication strategies, such as the Institute for Healthcare Improvement’s Ask Me 3 program, has been demonstrated to improve patient satisfaction and adherence. For more information, read our guide, Effective Patient Communication: Strategies for Challenging Situations.

Get Additional Assistance

Adding point-of-care imaging to an otolaryngology practice is efficient for practitioners, convenient for patients, and a source of revenue for the practice. It also comes with responsibility and potential risk. Our risk mitigation recommendations can help you increase safety and reduce risk.

For additional assistance, contact Patient Safety and Risk Management at (800) 421-2368 or by email.