Before going to law school, I was a hospital administrator. One of the hats that I wore in that job was that of the officer coordinating Joint Commission compliance.
The Joint Commission is the nation’s oldest hospital-accrediting organization. I can tell you that hospital leaders take their standards seriously, because failure to maintain accreditation puts funding from Medicare, Medicaid, and even third-party health insurance companies at risk.
Part of the accreditation process that the Joint Commission oversees is constantly raising the bar to improve healthcare and patient safety.
A December 2019 publication from the Joint Commission is a great example. It addressed the very real issue of diagnostic errors caused by test results falling through the cracks. I love the term that it uses to propose a solution to this critical challenge: closed-loop communication.
Closed-loop communication is when every test result is communicated, received, acknowledged, and acted upon. In other words, there is no room for failure from information falling through the cracks.
Unfortunately, most hospitals have a long way to go when it comes to opportunities to improve. And that’s true for both laboratory tests and diagnostic radiology studies, such as MRIs and CT scans. The standard of care requires laboratory and radiology personnel to directly communicate critical findings to the doctor who ordered the study and to the patient’s nursing staff.
Critical findings are information necessary to guide immediate treatment decisions, which can be the difference between life and death.
Take for example the case of a woman in her 40s who went to her primary care doctor for a routine annual mammogram. Mammograms are x-ray studies of the breast that are our front-line defense against breast cancer. The patient was told that if there was a problem, the radiologist would contact her.
It turns out that the radiologist who interpreted the mammogram did, in fact, see a suspicious area and wanted some more detailed follow-up imaging to see if it was cancer.
What happened next is a classic system failure.
The primary care doctor who ordered the mammogram wasn’t on the same electronic medical record system as the radiologist who interpreted it. As a result, the radiologist’s report never got back to the primary care provider.
The standard of care requires a doctor’s office to follow up on past-due radiology studies. When the radiology report didn’t show up, no one followed up. The physician blamed it on changes in the front office staff.
The radiologist didn’t call the patient because, according to him, an administrative staff member didn’t print out the complete list of patients who needed to be called. That makes me wonder who else’s care might have been compromised!
As a result of these overlapping system failures, a year went by before the primary care doctor figured out what happened, when it was time for the next mammogram. Meanwhile, the patient was found to have cancer, and it had progressed to Stage 3. She faced surgery, chemotherapy, and radiation.
A closed-loop communication would have eliminated this serious, life-threatening diagnostic error. Instead of leaving communication of this important information to electronic systems, healthcare providers should take the time to make sure everyone is in the loop. After all, it makes sense that if the study was important enough to order, it’s also important enough for all necessary follow-through.
Yet, incredibly, the Joint Commission reports that there’s no follow-up on up to 62% of laboratory tests and up to 35% of radiology studies.
If you’ve been seriously injured because someone dropped the ball concerning lab or radiology results, then contact a top-rated, experienced Houston, Texas medical malpractice lawyer to discuss your potential case.
