Of 380 communication errors occurring in the radiology department of an academic medical center over a 10-year period, 37.9 percent had a direct impact on patient care and 52.6 percent were potentially impactful, according to a study running in the March edition of the American Journal of Roentgenology.
More telling still, the majority of mistakes across those two impact categories happened outside of result communications. This suggests that systems need to be developed to guard against communication errors throughout the journey of patients and their data in the radiology department.
The price of failing to develop such systems, and accepting the status quo, would be allowing patient care, customer satisfaction and workflow efficiency to suffer.
Led by Bettina Siewert, MD, researchers at Harvard-affiliated Beth Israel Deaconess Medical Center in Boston arrived at this conclusion by grading communication-error impact on patient care on a 5-point scale from none (0) to catastrophic (4).
Then they compared severity of impact between errors in result communication and those that occurred at all other steps, including:
- Ordering (53 of 380, 13.9 percent);
- Scheduling (18 of 380, 4.7 percent);
- Performance of examination (114 of 380, 30.0 percent); and
- Study interpretation (14 of 380, 3.7 percent).
Result communication was the single most common step, accounting for 47.6 percent (181/380) of errors. There was no statistically significant difference in impact severity between errors that occurred during result communication and those that occurred at other times (p = 0.29).
In 144 of the 380 cases (37.9 percent), there was an impact on patient care: 21 minor impacts, 34 moderate impacts and 89 major impacts.
The team recorded no impact in 236 cases (62.1 percent), but 200 cases (52.6 percent) had the potential for an impact.
“An important communication guideline by the Joint Commission is the ‘write down and read back’ rule for abnormal results,” Siewert et al. write in their conclusion. “This acknowledges the well-known difficulties with verbal communication and could be addressed in radiology for most communications by replacing verbal communications with online written communications.”
At their institution, they add, they have turned the JC guidance into, for example, an online protocolling system for CT and MRI exams.
Communication errors in radiology are common, the authors emphasize, and have direct or potential impacts on patient care most of the time they occur.
“Although communication errors related to result reporting are important, they are outnumbered by errors of similar severity of impact occurring at other steps during a patient’s journey in radiology,” the authors write. “Therefore, more attention must be paid to communication occurring all throughout the radiology department, and systems must be developed to avoid these in the future.”