Critical findings lists can ensure timely calls, but beware overnotification

Creation of a critical findings list can help ensure adherence to communication standards, and one study found nearly 95 percent of cases at an institution with such a list were appropriately classified, with referring clinicians called when appropriate, according to results published in the May issue of the American Journal of Roentgenology.

The majority of mishandled cases in the study were not due to a failure to notify referring clinicians of a critical finding, but instead were due to overnotification by calling for a noncritical finding, according to study authors Valentina G. Viertel and colleagues from Johns Hopkins Medical Institutions in Baltimore.

“Calling clinicians to report noncritical findings may result in unnecessary interruptions in work flow for radiologists and referring health care providers,” wrote the authors.

Johns Hopkins utilizes a comprehensive critical findings list within the neuroradiology division to assist radiologists in taking the appropriate steps when they discover abnormalities, explained Viertel and colleagues. The list is posted throughout the division and distributed to all fellows and residents when they begin working in the division. This list becomes the first step toward satisfying the Join Commission’s National Patient Safety Goal Requirement for communication of critical findings.

The authors reviewed 3,054 neuroradiology CT and MRI studies, and found the vast majority were handled correctly. In 94.7 percent of cases, critical findings were flagged as such and referring physicians were called, or noncritical findings were identified correctly and referrers were not called.

A total of 301 reports in the study had critical findings, and 77.4 percent were flagged and spurred a call. In 24 cases, amounting to 0.8 percent of total cases, clinicians were not notified about a critical finding resulting in a potentially dangerous situation, reported the authors.

Overnotification occurred for 95 studies, constituting 58.3 percent of mishandled cases and 3.5 percent of cases overall, according to Viertel and colleagues.

“As our analysis proceeded, it became apparent that the types of critical findings varied by the time of day,” wrote the authors. “One third of all neuroradiology studies were performed at night; however, most of the critical findings were flagged during this lower volume time period.” Types of diagnoses also varied by time of day, with new hemorrhage most common at night, and new stroke most common during the day.

Reporting radiologists called regarding low-severity findings with higher frequency at night, and the authors speculated this may be because fellows or residents are responsible for interpreting these studies and providing preliminary reports. “One hypothesis for the increased frequency of calls to clinicians about low-severity findings at night may be a lack of confidence and lower experience level of the junior radiologist. This hypothesis argues for the adoption of department-specific lists of critical findings to assist radiologists-in-training about when it is appropriate to interrupt work flow for the delivery of such results.”