Critical Findings Research Articles

Classification and Communication of Critical Findings in Emergency Radiology: A Scoping Review

PurposeTo identify the published standards for the classification and communication of critical actionable findings in emergency radiology and the associated facilitators and barriers to communication and message management or dissemination of such findings. Materials and methodsSearch terms for resources pertaining to critical findings (CFs) in emergency radiology were applied to two databases (PubMed, Embase). Screening of hits using the following pre-established inclusion and exclusion criteria were performed by three analysts with subsequent consensus discussion for discrepancies: (1) the resources include any standards for the classification and communication of imaging findings as critical, or (2) the resource discusses any facilitators to the communication of CFs, or (3) the resource discusses any barriers to the communication of CFs. Resources with explicit focus on a pediatric population or predominant focus on artificial intelligence or natural language processing were omitted. Accompanying gray literature search was used to expand included resources. Data extraction included year, country, resource type, scope or purpose, participants, context, standards to identifying or communicating CFs, facilitators and barriers, method type, recommendations, applicability, and disclosures. ResultsSeventy-six resources were included in the final analysis, including 16 societal or commission guidelines. Among the guidelines, no standardized list of CFs was identified, with typical recommendations suggesting application of a local policy. Communication standards included direct closed-loop communication for high acuity findings, with more flexible communication channels for less acute findings. Applied interventions for CFs management most frequently fell into four categories: electronic (n = 10), hybrid (ie, electronic or administrative) (n = 3), feedback or education (n = 5), and administrative (n = 4). ConclusionThere are published standards, policies and interventions for the management of CFs in emergency radiology. Three-tier stratification (eg, critical, urgent, incidental) based on time sensitivity and severity is most common with most CFs necessitating closed-loop communication. Awareness of systemic facilitators and barriers should inform local policy development. Electronic and administrative communication pathways are useful adjuncts. Further research should offer comparative analyses of different CF interventions with regards to cost-effectiveness, notification time, and user feedback.

Critical Findings: Attempts at Reducing Notification Errors

PurposeIneffective communication of critical findings (CFs) is a patient safety issue. The aim of this study was to assess whether a feedback program for faculty members failing to correctly report CFs would lead to improved compliance. MethodsFifty randomly selected reports were reviewed by the chief of neuroradiology each month for 42 months. Errors included (1) not calling for a CF, (2) not identifying a CF as such, (3) mischaracterizing non-CFs as CFs, and (4) calling for non-CFs. The number of appropriately handled and mishandled reports in each month was recorded. The trend of error reduction after the division chief provided feedback in the subsequent months was evaluated, and the equality of time interval between errors was tested. ResultsAmong 2,100 reports, 49 (2.3%) were handled inappropriately. Among non-CF reports, 98.97% (1,817 of 1,836) were appropriately not called and not flagged, and 88.64% (234 of 264) of CF reports were called and flagged appropriately. The error rate during the 11th through 32nd months of review (1.28%) was significantly lower than the error rate in the first 10 months of review (3.98%) (P = .001). This benefit lasted for 21 months. ConclusionsReview and giving feedback to radiologists increased their compliance with the CF protocol and decreased deviations from standard operating procedures for about 2 years (from month 10 to month 32). Developing new ideas for improving CF policy compliance may be required at 2- to 3-year intervals to provide continuous quality improvement.

Opportunities for Targeted Education: Critical Neuroradiologic Findings Missed or Misinterpreted by Residents and Fellows.

We reviewed neuroradiology cases in which a resident or fellow missed a significant finding, to identify potential areas of deficiency that could be strengthened through targeted education. Included in the study were all neuroradiology reports from 2011 through 2013 that were marked with an electronic flag to indicate a significant modification between the preliminary and final versions. The reports were examined to determine whether a critical finding (CF) or a non-CF was missed, with the use of a hospital-approved list of 17 neuroradiology CFs. Results were analyzed for all trainees. A total of 978 modified reports were found among reports from 225,628 neuroradiology examinations. Of these modified reports, 891 (91.1%) contained an addendum that identified the discrepancy: 658 (73.8%) contained a CF,192 (21.7%) contained a non-CF, and 41 (4.6%) were changed from containing a CF to not containing a CF. A total of 725 missed CFs were found in the 658 modified reports. The CF miss rate for all trainees was 6.0% (95% CI, 5.6-6.4%), whereas that for residents was 8.6% and that for fellows was 4.8%. Residents missed hydrocephalus, intracranial pressure or edema, new hemorrhage, and new infarction more frequently than did fellows. The five most frequently missed CFs were congenital variation, infection, misplaced hardware, a new or enlarging mass, and vascular abnormality. Our trainees' overall CF miss rate was 6.0%. Five CFs had miss rates of approximately 10% or more, and residents missed four of the CFs more frequently than did fellows. With the use of these data, our curriculum could potentially be strengthened and our trainee error rates decreased, leading to improved patient care.

Continuous practice quality improvement initiative for communication of critical findings in neuroradiology.

The authors examined faculty's compliance with a hospital-approved neuroradiology critical findings (CFs) policy, which requires urgent verbal communication with the clinical team when 17 specific critical pathologies are identified. During June 2011 to July 2013, 50 random neuroradiology reports were sampled monthly for the presence of CFs and appropriate action. Faculty were provided ongoing feedback, and at the end of 2 years, the medical records for cases with noncommunicated CFs were reviewed to identify potential adverse outcomes. Of the 1200 reviewed reports, 195 (16.3%) had and 1005 (83.8%) did not have a CF. A total of 176 of 195 (90.3%) cases with CFs were communicated, and compliance increased from 77.4% to 85.6% (P = .027) since the monthly sampling was instituted; 1 of 19 (5.3%) noncommunicated CFs resulted in a potential adverse event. The ongoing monthly feedback resulted in improved faculty compliance with the CF policy. However, a small number of cases with CFs are still not being communicated.