Takeaway: If the ordering practitioner does not follow up, an incidental finding may lead to patient harm and result in a malpractice claim. Addressing follow-up as a systems issue can reduce risks for practitioners and organizations.
Background: Many practitioners have experienced how one incidental finding can lead to a cascade of care, meaning testing and treatment that may not provide medical benefit to the patient, or may even harm the patient, while also adding costs and contributing to clinician burnout. Incidental findings occur when medical imaging such as a CT scan, MRI, ultrasound, or X-ray reveal an unexpected and/or unrelated anomaly. Practitioner exasperation with this phenomenon is reflected in terms like “incidentaloma.”
Nevertheless, failure to follow up on incidental findings carries real risks for both patients and practitioners. Within a healthcare organization, practitioners can best reduce risks while being mindful to avoid cascades when the organization implements clear policies and protocols for identifying, communicating, and tracking the follow-up of incidental findings.
A New Analysis: As imaging technology evolves, incidental findings are being discovered more frequently. The Doctors Company has completed a new analysis of medical malpractice claims against our members in which an incidental finding was identified as a contributing factor.1
Missed Incidental Findings Don’t Occur in Isolation
The closed claims that involved incidental findings that we analyzed tended not to turn on one single dramatic event, though many culminated in serious patient harm. Our results included:
- Contributing factors such as issues with clinical systems, communication, documentation, shift work, and a lack of policies and procedures
- Missed incidental findings do not occur in isolation or from a single missed opportunity
- Injury severity tended to be high or disabling, with many claims involving death
- More than 41% of the claims studied included an indemnity payment
Tips for Malpractice Risk Mitigation: Focus on Protocols
One of the primary risk-mitigation strategies indicated by our analysis is to establish—or better implement—protocols and tracking systems. Although the specifics will vary by specialty, organizations share an imperative to develop and implement clear protocols for identifying, communicating, and managing incidental findings. Management should include follow-up and tracking to ensure that findings are appropriately addressed.
This recommendation for risk reduction through protocols is aligned with the goal of preventing cascades, because when physicians are asked to describe how cascades happen, they often reference a gap in practice policies and protocols.
Clinicians and organizational leaders can start with guidelines recommended by the American College of Radiology (ACR) to develop their policies and systems for tracking follow-up on incidental findings, or to revisit and refresh existing arrangements. Systems may initiate alerts to inform practitioners about incidental findings and to track communication and patient follow-up.
The key word is systems: Members of a panel nominated by the ACR and the American College of Emergency Physicians found consensus around treating actionable incidental findings as a systems issue. This means creating and/or strengthening approaches that rely not on the vigilance of individuals, but on the safety-net value of teamwork and systems to keep the completion of follow-up steps from falling through the cracks.
There’s room for debate about how to differentiate between systems-safety elements like protocols, policies, and guidelines. But to put our study results into action, it’s less urgent that we agree what to call these things, and more urgent that we agree we need them. Practitioners, teams, practices, and organizations can start with the medical professional societies for their own specialties and regions, and then work toward consensus within their teams about how to create new systems, or better implement existing systems, for following up on incidental findings. The most important step is to begin.
This discussion of incidental findings and how to mitigate the risks they reveal is based on Detecting and Addressing Incidental Findings: Medical Malpractice Claims, published by The Doctors Company.
Reference
1CRICO-Candello. Copyrighted by and used with permission of Candello a division of The Risk Management Foundation of the Harvard Medical Institutions Incorporated, all rights reserved. As a member of the Candello community, The Doctors Company participates in its national medical malpractice data collaborative.
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.