By Frank Mazza, MD
While radiologic procedures are improving patient care in the United States and around the world, the complexity of these procedures, including the use of high-alert medications and the risk of communication failures during handoffs, may contribute to medical errors. The risk of error is especially evident in cardiac catheterization and endoscopy laboratories, radiology, and other imaging settings where health care practitioners may administer medications such as contrast media, adjust rates of IV fluids, and flush IV access lines.
Radiology errors pose yet another level of challenges for hospitals and providers operating in the new health care reform environment: Payments have become increasingly and explicitly linked to a complex myriad of performance measurements, and nonperforming providers face greater financial risk. Tackling these payment obstacles often requires a transformation of clinical operations within the radiology department and the establishment of an infrastructure that incorporates a solution platform aimed at improving patient care and safety. The process can effectively begin with improvements in staff communication and patient identification.
First Key Challenge: Communication
The Joint Commission recently released its national patient safety goals on critical values reporting, with an emphasis on getting "important test results to the right staff person on time." The communication must be timely and requires documentation of a closed loop of communication between the originator of the critical information and the provider or his or her surrogate. A clinically significant condition might require active outreach to the physician so that he or she is aware of the finding.
In a radiologic setting, such conditions include an unexpected lung cancer or a newly discovered pneumothorax on a routine chest X-ray. The Joint Commission states that there must be a process to address these situations and their inherent challenges. First, the radiologist must contact the physician when issues arise. But what are the criteria the radiologist should use? What if the physician doesn't respond to the communication? The radiologist is still responsible for contacting the physician in a timely fashion.
An additional concern could arise if the physician has signed out to someone else. What if the radiologist's shift has ended, and he or she must pass off the responsibility? What is the time frame for expecting a response for an emergency? When a call is made to a physician, how is this documented?
Critical information that is not passed from one provider to another is a significant cause of medical malpractice claims and an important patient safety issue. For instance, once the radiologist makes the decision to call the physician, it can be difficult to know whether the interaction should be "once and done" or if there is an ongoing need for communication.
For example, if a patient experiences a lung collapse one day, but the lung is slightly larger the next day, should this require a second call to the physician, who may already be aware of the problem? Clearly, no one wants to hold back important information that could lead to the harm of a patient. At the same time, radiologists must be careful about contacting the physician too many times to avoid being excessively intrusive or triggering a response akin to "alert fatigue."
Second Key Challenge: Patient Identification
Identifying the right patient, right side/site, and right procedure holds the same level of importance for numerous invasive procedures performed in IR suites as it does in operating rooms. Consider this famous case from the Annals of Internal Medicine:
A woman, 67, was admitted to a teaching hospital for cerebral angiography, which was performed, and one of the aneurysms successfully embolized. The second aneurysm was deemed more amenable to surgical therapy, for which a subsequent admission was planned. After angiography, the patient was not returned to her original bed on the telemetry unit; she was transferred instead to the oncology ﬂoor. Discharge had been planned for the next day, but, the following morning, the patient was taken to undergo an invasive cardiac electrophysiology study. About one hour into the procedure, it was determined that she was the wrong patient. The study was aborted; she was returned to her room and was in stable condition.1
The point of this article was that there was a systematic series of errors—16 in total—related to a recurrent pattern of failure to exercise the necessary degree of rigor in identifying the correct patient, at the risk of significant harm to her. To ensure patient safety, there must be an appropriate "time-out" performed by the team, two-person identifiers should be used, and the correct site/side marked beforehand. In general, facilities should aim to optimize their day-to-day operations and unlock value in health care by improving quality and safety. This requires a commitment to standardizing an approach to the care and measuring of outcomes.
For addressing all of these challenges, the question becomes, is there an all-inclusive solution that blends functionality centering on safety risk management and surveillance, pay-for-value reporting, and performance analytics?
Finding a Solution
Hospitals seeking such a solution should look for a combination of software as a service-based solutions and EHRs, either on a standalone or fully integrated basis. This blend will more effectively monitor and measure clinical and financial performance with precision and conviction. EHR vendors must take the lead in working with clients to embed standardized order sets and clinical processes into EHRs and create software solutions that automate and aggregate outcomes-data collection. A data platform that allows provider benchmarking based on resource utilization and condition-by-condition clinical outcomes should be included as a critical component.
The good news is that episode evaluation systems exist that can span the entire continuum of patient care. Unlike traditional encounter-based systems, these have the capacity to capture all clinically related encounters and assign them to a single episode of care, regardless of setting. This allows providers and purchasers to accurately compare total cost and resource utilization against local peer groups, national norms, and generally accepted best practices. It also gives providers the power to measure what matters, using meaningful and reliable information for assessing the integrated delivery of cost-effective care.
— Frank Mazza, MD, is the CMO of Quantros. He is a physician by training (pulmonary, critical care, and sleep disorders) and still practices medicine part time.
1. Chassin, MR, Becher, EC. The wrong patient. Ann Intern Med. 2002;136(11):826-833.