Communication problems at the root of radiology errors, prof says

Unfortunately, mistakes happen in medicine & up to 100,000 deaths occur annually in the United States due to medical errors, according to studies, and a proportionate number happen in Canada, as well.

While medication errors and misdiagnosis are major root causes, the top cause of preventable errors are communication breakdowns.

“The Joint Commission found that 65 percent of SREs [serious reported events] reported to them are due to communication errors,” said Dr. Bettina Siewert, assistant professor of radiology at the Harvard Medical School, in a presentation at the RSNA conference in Chicago last fall.

In her address, she focused on radiological errors and asserted that mistakes in communication are the major cause of errors there, too.

“In our own hospital system, 56 percent of radiology errors were due to miscommunication,” she said.

She then went on to analyze these errors and to recommend ways of reducing them.

Dr. Siewert stated that because of communication errors in radiology, patients will have unnecessary radiological exposure, delays in the diagnosis of a malignant finding or unnecessary surgical intervention.

“Even a delay in a benign development is not a minor event,” she said. “A benign result in breast cancer, for example, could have a grave impact on a patient who was worried and anxious all along.”

Also, additional follow-up imaging is not only harmful to the patient but of high cost to society, she said.

“The effect on patients is severe and is completely underestimated.”

Moreover, she said that patients feel disrespected and see healthcare providers as incompetent, and not being able to communicate. “Which they feel is part of our job,” she noted.

In the case of transcription errors, patients feel that radiologists are not paying attention and are not doing a thorough job.

This leads to a loss of trust in the medical system & with some patients leaving the healthcare system altogether.

“Our referring physicians also lose trust, and send their patients elsewhere,” she said.

Dr. Siewert pointed out that communication errors also affect workflow efficiency. It takes extra time and effort to remediate errors in reports, for example, and to reschedule patients for exams or get a patient in as an add-on.

“This is something we can ill-afford in these times of short staffing,” she said.

Much of this work, moreover, falls on the shoulders of QA managers, who deal with incident reports and patient complaints.

“While service recovery is possible, it takes an inordinate amount of time,” she stated. And of course, communication errors lead to malpractice risks.

“Eighty percent of malpractice cases have a communication component,” said Dr. Siewert. “Jurors do not want to hear that a radiologist was too pressed for time to communicate for five minutes to a referring physician,” she said.

Nevertheless, the communication process in radiology is quite complex. From ordering the test to scheduling the exam, performing it, interpreting and relaying the results, multiple staff are involved. “There are many interchanges that are happening,” observed Dr. Siewert.

In her own department, for example, 30 percent of the communication errors occur at the performance of exams, and 48 percent occur with result communications.

“Errors at the time of ordering or in post-procedural care were less common,” she said.

When do errors occur in terms of who speaks to whom?

She noted that handovers are the most vulnerable times.

Communication between radiologists and referring physicians are the most vulnerable to communication errors, she said, followed by technologists and transport staff.

Communication between radiologists and technologists is also a pain point.

“Awareness of these miscommunications is needed when we are trying to avoid them,” she said.

What are the types of communication errors in radiology, she asked. Most commonly, they consist of:

• Missing information or incorrect information
• Lack of a closed loop [ensuring that information gets to the intended person]
• Key individual was not contacted
• Dr. Siewert said one way of counteracting these mistakes is by using human factors in engineering. “This has been shown to improve many aspects of healthcare and has been used to reduce communication errors.”

Examples of effective solutions include:

• Checklists, to ensure that all information is included in a report
• Closed loop systems, to ensure that the appropriate people have been contacted
• Standardization

Particularly effective are “forced function” solutions in closed loop systems. They ensure that all necessary information has been included and that key individuals have been contacted.