The accident occurred at the Ofuna Chuo Hospital in Kamakura, Japan. A chest physician failed to recognize an abdominal aortic aneurysm (AAA) on a follow-up CT scan for lung cancer. The physician paid attention only to lung cancer, neglecting to view other images and the radiologist's report, after which the patient died due to the rupture of the AAA, according to Yousuke Aoki, a technologist in the Department of Radiology and Radiation Oncology Center, and colleagues.
"In our hospital, when radiologists detect unexpected significant and/or urgent findings, they attempt to inform the referring physician by telephone. In this case, however, the referring physician could not be reached, because he was out of hospital," they explained in an e-poster presentation at ECR 2017. "This experience motivated us to develop a system providing alert notices for significant and/or urgent findings to referring physicians."
How the system works
Under the alert system implemented at Ofuna Chuo Hospital, radiologists who detect an urgent finding select the examination from the PACS list view and activate the alert system on the examination, a function the system defines as "expand action." The PACS sends the accession number and the report of the examination to the electronic health record (EHR), which generates an urgent message from the information sent by the PACS. This message is displayed on the referring physician's screen.
If the referring physician does not log on to the EHR, the system activates at the next log on, and while this message is displayed, other functions are locked, and if the referring physician continues to avoid the message, the system issues further warnings at constant intervals. After three business days, the warning is sent to all the doctors in the physician's department.
Between October 2014 and October 2016, 204,957 reports were made at the hospital, Aoki and colleagues reported. Of these, 476 reports had significant and/or urgent unexpected findings and needed activation of the alert system. Reports with activation were confirmed more frequently within three days than those without activation (97.9% versus 9.0%; p < 0.05), and within seven days (100% versus 9.6%; p < 0.05).
"We found the reference point of evaluation, to achieve 100% communication between the radiologist and the referring physician, can be completed in seven days in this system," they noted. "This system can play a role in ensuring communication among medical staff."
They suggest not using the alert system for all reports, however. Using it often would risk making the referring physicians too accustomed to the alerts and lose interest, thereby not aiding communication. Limiting the system to significant and/or urgent findings means it would be used in about 0.2% of cases, and this rare frequency would strengthen the value of the warning, the authors wrote.
Alerts to other physicians
Activation of the "expand action" facility does an efficient job of making referring physicians aware of missed reports, the authors said. This facility has proved particularly useful in the case of referring physicians who work part-time, who are retired, or who are on a lengthy vacation. It has also helped when referring physicians were not familiar with the operation of the alert system (e.g., when they only worked at the hospital for a short time).
The alert system can help avoid neglected reports of unexpected significant findings, and it is designed to make information more easily shared, they added. Separate qualitative audits may be useful to evaluate whether the practice is affected by the shared information. At Ofuna Chuo Hospital, currently staff check the contents of the medical record manually, but from now on the automation of qualitative audits and evaluation is under consideration.
"In Japan, it is important to communicate information within the EHR," Aoki and colleagues stated. "Overall clinical care from diagnosis to treatment is completed within one hospital, and the EHR is a common language in the Japanese medical environment."
Appropriate communication is an essential way of ensuring medical safety, and tools like alert systems contribute to good communication, they concluded. Follow-up of noncritical actionable findings is being examined by the Integrating the Healthcare Enterprise (IHE), raising hopes that greater standardization will occur.
To view the full e-poster presented at ECR 2017, click here.
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