Patient Safety Strategies for Radiology
Expediting critical or nonroutine results to requesting providers is of utmost importance for patient safety. Radiology is frequently called upon to expedite results. For emergent or other nonroutine clinical situations, have a process in place that expedites delivery of diagnostic imaging reports to ensure timely receipt by the respective department or physician (such as for surgery or the emergency department physician). Include discrepant findings from preceding interpretations. Document the medical record with how and when the results were communicated.
If you practice in a facility that schedules self-referrals for tests, such as mammography, CT, or MRI, make sure you have established policies and procedures that require appropriate follow-up communication with the patient, the patient’s primary care physician, and any consultant as indicated.
Patients who are self-referred have established a physician-patient relationship with you. As the radiologist, you are responsible for communicating the results of imaging studies directly to the patient, as well as to his or her physician, and for arranging appropriate follow-up care with the patient’s physician. Again, documenting the communication is key.
When sedating patients for imaging studies, consider the following guidelines:
- Use a preprocedure checklist.
- Ensure there is a preoperative medical history and examination of each patient.
- Follow age-specific fasting guidelines.
- Provide uniform training and credentialing of providers.
- Make sure age- and size-specific equipment and supplies are available.
- Include a procedure for patient observation and monitoring.
- Maintain consistent record keeping with continuous assessment and recording of vital signs.
- Implement a written protocol for recovery and discharge.
Effective communication is a critical component of diagnostic imaging services, and it is the radiologist’s responsibility to provide the exam results and any other relevant information. The handoff and communication of results affect the quality of patient care. Whenever possible, review previous reports and images and perform comparisons with the current study. Communicate significant abnormal findings appropriately and in a timely manner directly with the treatment team.
At a minimum, include the following components in your final report:
- Patient demographics.
- Relevant clinical information.
- Impression (conclusion or diagnosis).
- Recommendations for follow-up studies when appropriate.
Kuzminski SJ. Recommend clinical correlation: a common but meaningless phrase in radiology reporting. J Am Coll Radiol. 2015 Aug;12(8):775. Accessed September 14, 2016.
Munn S. Inadvertent ≠ accidental. J Am Coll Radiol. 2015 Sep;12(9):897. Accessed September 14, 2016.
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.