Jonathan Bruce Kruskal, Presenter: Nothing to Disclose

Chun-Shan Yam PhD, Abstract Co-Author: Nothing to Disclose

Donna Hallett, Abstract Co-Author: Nothing to Disclose

Jacob Sosna MD, Abstract Co-Author: Nothing to Disclose

Vassilios D. Raptopoulos MD, Abstract Co-Author: Nothing to Disclose

Medicolegal constraints and state regulatory agencies are increasingly demanding accountability for medical errors. Communication of critical results is such a target, and few systems currently exist in clinical radiology Departments in this country. Based on a sentinel event resulting from failure to communicate a critical radiology finding, our PCAC requested that we develop, implement and monitor a policy for communicating critical results. This study describes the process for implementing this policy, and for continuous monitoring of physician compliance.

Our Radiology Quality Management Team process was 1) to define critical results, 2) to get physicians on-board, 3) to implement the process and 4) to continuously monitor compliance. Through a workshop coordinated by the Massachusetts Coalition for Preventing Medical Errors, critical radiological findings were defined (red flag=immediate documented direct communication or yellow flag=documented communication within 3 days). Following staff agreement and approval by our Core Clinical Service Committee, the communication process was implemented via repeated e-mail notification, website posting and direct verbal presentation. For continuous monitoring of compliance, a software program has been written to search for key words in reports.

Twelve specific results requiring documented communication were defined and agreed upon by all staff radiologists and QA Directors from all clinical Departments in our hospital (n=12). In parallel with clinical implementation, a system for telephonic and e-mail communication, for electronically identifying the responsible ordering physician, and for documenting this communication was established. Once advertised and active, continuous computer monitoring served as an effective clinical backup for cases not immediately communicated (n=4), but identified delays in communication (n=12) and reminded radiologists (n=3) to communicate these findings.

In response to clinical and regulatory needs, we have implemented a novel process for defining and communicating critical radiological findings, and for continuous and interactive monitoring of this compliance.

Kruskal, J, Yam, C, Hallett, D, Sosna, J, Raptopoulos, V, Instituting and Continuous Monitoring of a Policy for Identification and Communication of Critical Radiology Results.  Radiological Society of North America 2005 Scientific Assembly and Annual Meeting, November 27 - December 2, 2005 ,Chicago IL. http://archive.rsna.org/2005/4413060.html