Most radiology services, including an emergency radiology service, do not schedule dedicated clinic time, and therefore meeting with patients may not be a set priority in the daily workflow. Strategies for minimizing fatigue can include limiting workload to only truly emergent cases while on call, having overlapping or short call shifts, and providing more coverage to high-volume areas like ED CT. For radiologists in the emergency department (ED), the physician-to-patient communication can come with a different level of challenges. To begin, it is important to be aware of the time constraint, especially in the busy setting in the ED. As a Level I Trauma Center, Level I Pediatric Trauma Center, and Level I Burn Center, Mass General is accredited to treat patients with the most critical injuries and sees over 110,000 patients per year. During a trauma code, the emergency room is loud and frenetic with ongoing resuscitation and a large trauma team. The radiologist can also inform the patient that ED providers and the patient’s primary care providers will be able to access the images and the radiologist’s interpretations. Subspecialty training may be beneficial or required in certain areas, and it is important that radiologists acquire such subspecialty training when it is needed. Patients might indicate, through their body language, emotions that they do not feel comfortable expressing out loud. Although telephone calls are a common distraction, they are by no means the only type of interruption that can increase errors and detrimentally affect safety. In this complex environment, radiologists can help reduce patient anxiety by outlining the process as clearly as possible. Resident and/or staff fatigue is another cause of errors, and several studies have demonstrated how overwork affects accuracy and its medical-legal implications. In an ED setting, radiologists frequently receive incomplete or irrelevant clinical history, which can be a major source of error and inefficiency. A common scenario in a teaching institution would be when an attending’s final report contains a discrepancy with the overnight resident’s preliminary impression. Although difficult, interrupting resuscitation is acceptable when the findings are emergent and will change management, but information conveyed should be concise and clear. Hopefully, by employing some of these tactics, such situations become the rare exception to what are largely cordial workplace relationships with ED providers. Our radiologists are responsible for the interpretation of emergency imaging at VCU Health and its affiliated Level 1 Trauma Center and comprehensive stroke center. Example for gathering additional clinical information: “Hi, I am Dr. Smith. Having a systematic method for capturing safety events should encourage ongoing analysis, timely response, and data gathering for systematic review. These are undesirable clinical outcomes resulting from some aspect of diagnosis or therapy, not from the underlying disease process. An upright CXR is one of the preferred x-ray views for detecting pneumoperitoneum, however this requires the patient to be sitting or standing erect for a few minutes prior to shooting the film to allow the air to rise caudally under the hemidiaphragms. Four out of five malpractice lawsuits in radiology involve complications in communication. Essential components include date, time, name of the person spoken to, and the information discussed. Radiologists often overestimate the time needed to review images with a patient. Physician-to-patient communication is a unique challenge for radiologists. With recent healthcare reform, reimbursement will soon be tied to patient satisfaction. Specialized X-rays taken from multiple angles are converted into a detailed, three-dimensional (3D) image. Dear guests, On behalf of the Conference Committees, it is my pleasure to invite all of the radiologists, radiographers, clinicians, residents and medical students to attend our international radiology conference "Pearls in Emergency Radiology" from February 12-14, 2020 at the Sheikh Jaber Cultural Center, Kuwait. Emergency radiology departments must have standard policies regarding what is expected and appropriate for preliminary interpretations so that radiologists and emergency providers have consistent expectations. Online case-based review of emergency radiology featuring over 8 hours of video recordings by Dr Andrew Dixon, A/Prof Frank Gaillard and guests. Reading of preliminary reports by attending and/or subspecialty radiologists should be performed in a timely fashion, with consistent expectations regarding the time from preliminary to final interpretation. This includes findings that were not present on the original image due to an inadequate exam. Radiologic finding missed on chest x-ray on a busy call day. However, the ACEP guidelines actually state that head CT is not indicated in syncope unless there is focal neurologic deficit, significant head trauma, or some other factor guided by history or physical exam.”. Emergency Radiology Question: Which x-ray views are preferred for detecting pneumoperitoneum? Overworked radiology departments with suboptimal workflow will tax all components of the system and are a setup for system-related errors. Such data suggest tremendous opportunities for radiologists and emphasizes the increasing importance of effective conversation skills when delivering study results to patients. Potential areas of service failure include the following: Hospitals may be inadequately staffed to provide quality emergency radiology services on a 24-hour basis. It summarises the major problems faced on-call and provides advice on the most suitable radiological tests to request as well as suggesting an appropriate timescale for imaging. It is insufficient to simply communicate findings and results. Communication skills, negotiation strategies, and a touch of charisma are essential. Any unscheduled workflow disruption can force the radiologist to disengage from his or her interpretive tasks and, in the process, forget the context and mindset that existed prior to the disruption. Acquiring facial photographs simultaneously with radiographs has also been reported to increase detection of mislabeled examinations without sacrificing interpretation time. The American Society of Emergency Radiology was formed in 1988 from this small nucleus and has steadily increased in numbers and interest, providing consultation to radiologists and corporations who deal with emergency radiology challenges. This is also called a blunt-end error, as opposed to an active or sharp-end error, where the source of error lies with the personnel or parts of the healthcare system in direct contact with patient. In a root cause analysis (RCA), handoffs and resultant patient safety events have been shown to be particularly prone to error when information is exchanged via the telephone, which is especially applicable to emergency radiologists. At its most effective, emergency radiology provides frictionless tools and support to allow emergency healthcare personnel to provide safe, effective, patient-centered care. Patient sued clinic for missed Lisfranc fracture on a digitized radiograph. Radiology exams include: CT scan (computed tomography). Emergency diagnostic radiologists are an integral part of a hospital’s emergency team and are directly involved in helping diagnose trauma patients. In the United States, an estimated 44,000 to 98,000 deaths per year may be attributable to medical errors and cost $17 to $29 billion. This is required to provide good patient care and for maintaining hospital credentials, board certification, and licensing. It issues no invitation to any person to act or rely upon such opinions, advices or information or any of them and it accepts no responsibility for any of them. However, situations requiring radiologist-to-patient communication may still occur. However, emergency radiologists may encounter examinations for which they do not feel properly trained or have not maintained their expertise, which can lead to errors and suboptimal care. In lawsuits, an ordering physician can claim ignorance of the proper actions following a radiology diagnosis, because the radiologist did not provide recommendations. However, this is particularly challenging in the ED because treatment plans are often in flux during emergent situations, and there are multiple teams involved in caring for any single patient. I usually work behind the scenes with your emergency medicine team to review imaging studies so that the team can use the results to decide on an appropriate treatment. Incorrect contrast dose was administered because the tech who programmed the injector confused it with a different model used in the department. Being aware of these emotions and validating them verbally can be particularly useful in stressful environments like the ED. In conversation, use the keywords “brief” and “quick” to demonstrate respect for their time and the frenetic nature of their specialty. Communicating nonurgent incidental findings should take place after the resuscitation is completed. The ACR fully supports and recommends compliance with the Centers for Disease Control and Prevention (CDC) guidance that advises medical facilities to “reschedule non-urgent outpatient visits.” This includes non-urgent imaging and fluoroscopy procedures, including but not limited to: screening mammography, lung cancer screening, non-urgent computed tomography (CT), ultrasound, plain film X-ray exams, magnetic resonance imaging (MRI) and other non-emergent or elective radiologic and radiologically gui… To support the radiologist in this effort, hospitals and radiology departments must ensure that there is a robust system for archiving and storage of old studies, such that pertinent comparison exams are readily available when needed. Provides clinical material on radiology procedures that define your role in managing a patient with an emergent condition. It is important to be very clear, especially when offering two or more diagnoses, and explain to the ordering provider why certain differential diagnoses are more or less likely. Nonetheless, standard practices must be implemented to ensure that discrepancies that do occur are managed in a timely and routine fashion to minimize any adverse effects on patient care. A service performing suboptimally over a period of time producing unsatisfactory outcomes. Interventional radiology procedures are an advance in medicine that often replace open surgical procedures. Or would he or she be willing to wait for a brain MR sometime this week?”. Radiologists may need to explain medical terminology in simple phrases that are easier for the general public to understand. If any recommendation was conveyed verbally, it is helpful to include it in the communication section as well. Failure to communicate results of radiologic examinations is reportedly the second most common cause of malpractice litigation with communication problems a causative factor in up to 80% of cases. Portable radiographs are very common in emergency radiology and particularly prone to error. Radiology of Skeletal Trauma (Second Edition).Churchill Livingston, New York; 1992. The following list of strategies will help radiologists improve communication skills with patients and family members in the ED. Some of the tests and procedures included in this publication may not be available at all radiology providers. For example, “Unable to convey results to attending physician (Dr. Smith); the above critical finding was conveyed to the senior resident (Dr. Jones) in the ED.”, An incidental finding may not seem like a priority in the busy ED setting, but communication and documentation are still necessary to ensure needed outpatient workup. In many cases, at the time the examination is ordered, data gathering is ongoing, so the emergency provider does not yet have all relevant information., Level 9, 51 Druitt St Radiologists must also be attuned to the needs and priorities of their ED colleagues, namely, assistance in rapidly triaging severity of pathology and provision of timely and accurate diagnoses. In a large retrospective review of near-miss wrong-patient events, Sadigh et al. This test produces 3-D images of the body using a large magnet and additional technology. Tone is directly related to one’s facial expressions, body language, and hand gestures, which unfortunately are absent in most provider conversations. found that portable chest radiography accounted for most mislabeling-misidentification events (69%) and wrong dictation events (44%). For example, if the radiologist is asked to perform a FAST exam at bedside, it is helpful to specify how the result will be communicated to the ED provider, whether via phone or in person. In one series, the mean time between when a mislabeling-misidentification event occurred and when it was detected was 100 hours, which could result in severely compromised patient care. In the ED, this may include recommendations to consult other specialties, such as general surgery or interventional radiology, although radiologists should be careful that such subspecialty consultations are truly warranted. This alone can convey that the physician has dedicated time to the patient and can foster an environment conducive to establishing trust. Each person should rely on their own inquires before making decisions that touch their own interests. McCort JJ, Trauma Radiology. I understand that you are the sister. Example for performing a FAST scan: “The study is normal. These phrases also represent a small form of flattery and can validate self-esteem, which may be important as hostile conversation often develops as a result of our colleagues feeling that their professional competence and reputation are under attack. Knowledge of certain measurements encountered during common emergent studies can help alleviate this stress and help the resident provide accurate and timely patient care. Example for gathering additional clinical information: “On your foot x-ray, there is a tiny crack in your bone at the same spot where I just pressed. The Radiology Department of Kuopio University Hospital serves at five different locations. From what you told me, this may be a stress fracture from increased running with the new marathon training program you recently started.”. In emergency radiology, it is helpful to have access to an ED whiteboard that is updated in real time to minimize time wasted contacting the incorrect provider. Finally, satisfaction of search is an error that can occur after detection of an initial lesion, when radiologists can experience reduced perception of other abnormalities, resulting in false-negative interpretations of secondary lesions. Even with the limited time available, it is crucial to give patients a chance to ask questions. Radiologists can minimize the risk of lawsuits by clearly documenting when and how results are communicated to other providers and to patients. Myriad factors drive ED physicians in their request for inappropriate or suboptimal imaging studies. Increasing patient awareness of the radiologist’s role in their care is a valuable way to incorporate radiology in patient-centered care. The training program will result in tremendous lasting benefits to the trainee and the community served by the trainee. Interventional radiology (IR) refers to minimally invasive, image-guided medical treatments. The source of this tension is rooted in some of the most common themes underlying medical staff conflict, namely, deficiency in communication, a lack of trust, and incorrect assumptions. A summary of possible errors, scenarios, and recommendations are summarized in Table 26.1 . Radiologists should also be mindful of the patient’s privacy and always confirm whether the conversation should be conducted alone or in the presence of the other visitors. In one study, Kuhlman et al. By adding this noninterpretive expertise, emergency radiologists can be better prepared for situations that arise and become even more valuable members of their clinical team. In addition, it can be helpful to have images ready or to use hand gestures to provide visual context for the verbal explanation. In conversation, use the keywords, “Have you considered?” or “Have you thought about?” to demonstrate regard for their clinical judgment and expertise. The radiologist should directly answer any questions pertaining to the imaging results but defer to the ED providers regarding management plans. It can be useful to initiate communication by explaining the special role that radiologists play in patient care, which is significantly different from the roles of other clinicians that patients usually encounter. Emphasize your commitment to the relationship by stating, “I am happy to do what you feel is best, and from my point of view, this has been an educational and productive conversation.” Medicine can be a contentious profession, and it is difficult not to take altercations personally. The types of scenarios requiring noninterpretive skills are quite varied, ranging from communication and risk management to serving as a chaperone or managing intravenous contrast extravasation, which can make managing them particularly difficult for many radiologists. Musculoskeletal and Emergency Radiology The musculoskeletal (MSK) and emergency radiology section is comprised of board-certified radiologists with particular interest in orthopaedic and emergency radiologic diagnosis, diagnostic procedures and therapeutic interventions. found that 85% of patients want to see images as part of the conversation when they receive results. Emergency radiology refers to imaging exams used to diagnose a sudden illness or traumatic injury. Emergency Radiology informs its readers about the radiologic aspects of emergency care. ASER members receive the journal as a benefit of Membership. Rather than focusing on individual errors, modern safety practices emphasize organizational elements that promote safety and use error to identify and analyze weaknesses in the system. The term is a reference to the martial arts technique of redirecting one’s attacker and describes phrases we can use to defuse escalating tension. To support the radiologists, emergency radiology departments should be proactive and establish frictionless mechanisms for accessing the medical record during the course of image interpretation. In addition to answering questions patiently, the radiologist should reassure the patient that there will be future opportunities to ask questions. The radiologist provides coaching: “You’re right, it is important to rule out acute pathologies in the emergency setting. Handoffs are ubiquitous in emergency radiology, occurring whenever patient information and responsibility are transferred between healthcare providers, and are among the greatest threats to patient safety. Additionally, it is good practice to document multiple communications when multiple attempts were made or if a radiologist conveyed findings to multiple services on the same study. It can also occur when a finding is attributed to the wrong cause. For example, “This is not an emergent finding, but further outpatient workup is recommended.”. Individuals in this environment must be taught situational awareness and encouraged to detect potential adverse events before harm is caused. At its most effective, emergency radiology provides frictionless tools and support to allow emergency healthcare personnel to provide safe, effective, patient-centered care. Documenting communication accurately is a crucial component of the patient’s medical record and for minimizing radiologists’ litigation risk.