Otolaryngology: Reduce Risk When Performing Diagnostic Imaging Services

Sue Boisvert, BSN, MHSA, Patient Safety Risk Manager II

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 physicians 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 program. 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 physicians 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. For example, the American Academy of Otolaryngology–Head and Neck Surgery provides guidance on the performance of CT and cone beam CT (CBCT). The American Institute of Ultrasound in Medicine (AIUM) and American College of Radiology (ACR) provide practice parameters for ultrasound. Continuing education requirements, mandatory procedure performance volume, and phantom testing, peer review, and overreads can be used to demonstrate ongoing competency.

Seek Accreditation for Each Modality

Specialty accreditation by service line indicates that minimum standards for physician 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 and facilitate comprehensiveness. Studies suggest that structured reports are preferred by referring providers, facilitate quality improvement measures, and may increase reimbursement.1,2 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 of imaging scans contain at least one incidental finding. These findings are confounding to providers and can result in a “cascade” of services and testing when pursued.3 

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 addition to applying skill and judgment, providers 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 providers 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 2009 and 2018 indicates that poor rapport with the provider was a significant contributing factor, followed by patient nonadherence with the treatment plan or follow-up.

While some of the 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 have been demonstrated to improve patient satisfaction and adherence. For more information, read our article “Rx for Patient Safety: Ask Me 3.”

Get Additional Assistance

Adding point-of-care imaging to an otolaryngology practice is efficient for providers, 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 the Department of Patient Safety and Risk Management at (800) 421-2368 or by email.


  1. Nguyen Q, Sarwar A, Luo M, Berkowitz S, Ahmed M, Brook OR. Structured reporting of IR procedures: effect on report compliance, accuracy, and satisfaction. J Vasc Intervent Radiol. 2018;29(3):345-352. https://www.jvir.org/article/S1051-0443(17)30955-7/abstract
  2. Dobranowski J, Sommer W. Structured radiology reporting: addressing the communication quality gap. SN Compr Clin Med. 2019;1:397-407. org/10.1007/s42399-019-00066-5
  3. Ganguli I, Simpkin AL, Lupo C, et al. Cascades of care after incidental findings in a US national survey of physicians [published correction appears in JAMA Netw Open. 2019 Nov 1;2(11):e1916768]. JAMA Netw Open. 2019;2(10):e1913325. Published 2019 Oct 2. jamanetwork.com/journals/jamanetworkopen/fullarticle/2752991.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

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