The initial chest x-ray and spirometry report were normal. The patient, Chris, was a 32-year-old male with a 10-pack year history of smoking and an intermittent non-productive cough but no other significant past medical history. The GP’s referral to the radiologist had noted concern about the potential for stonemason’s silicosis, based on a recent employment history of installing kitchen benchtops. The GP’s clinical note had prompted the radiologist to include in the report that while the chest x-ray showed no abnormalities, it was insufficient to exclude silicosis and that a high-resolution CT chest was recommended. The GP did order follow-up scans, which showed bilateral diffuse ground-glass opacities. The GP referred Chris to a respiratory physician for further assessment and Chris was recently diagnosed with accelerated silicosis.
Effective communication between primary care and diagnostic specialists can be key to a successful diagnosis, as this case illustrates. Unfortunately, many of the cases Avant sees have played out rather differently. Radiologists will probably not be surprised to learn that missed or delayed diagnoses were among the most frequent issues we have assisted radiologist members with.
Complaints and claims involving diagnostic error in radiology
A recent analysis of complaints and claims data, indicated that diagnostic errors were behind 66% of the claims for compensation and regulatory complaints involving Avant’s radiologist members. Three out of four of these involved allegations of a missed or delayed diagnosis, for example due to incorrect interpretation of an image, or delay or failure to report on an incidental finding. Diseases of the respiratory system were common among the missed or delayed diagnoses in the sample we analysed.
There are a number of practical steps radiologists can take to avoid errors in interpreting clinical images1. However, in over half of the cases in our data review, the radiologist’s care was assessed as having met the expected standard. This suggests that any failure to make a diagnosis was not due to an error interpreting the original image. Are there other steps radiologists can take to avoid being subject of claims or complaints? One other issue we see is where communications break down between some of those involved in the diagnosis – diagnostic specialists, primary care practitioners, and patients.
Encourage effective communication
The NSW Clinical Excellence Commission guidelines on avoiding diagnostic error2 encourage primary care practitioners to “speak directly with the staff providing you with diagnostic test results: radiologists, pathologists, and clinical pathologists. If you aren’t sure of the most appropriate diagnostic strategy, ask, or use online test-ordering advice.” For radiologists, it may be helpful to encourage referring practitioners to take this approach to communication. If you need more information on clinical history or differential diagnoses to aid your examination, ask for clarification from the referring doctor and / or patient if possible.
Specifically in the case of silicosis, awareness of this disease affecting young men working with artificial stone is increasing in Australia, in part thanks to recent media coverage and the announcement of a National Dust Diseases Task Force3. The Royal Australian and New Zealand College of Radiologists’ recent release of guidelines on screening for silicosis also attracted attention in the medical media4. However primary practitioners may not have seen cases of silicosis and may not always be aware of screening recommendations. Considering silicosis as a potential differential diagnosis and recommending further testing as appropriate in your report may be key to successful and early diagnosis. Following up directly with the referring doctor if there is any doubt may also be appropriate.
Be clear about the limits of testing
We also see problems arising because of misunderstandings about the limitations of radiologic studies. In both your reports and in any direct dealings with patients, it is important to explain when tests may not be enough to rule out a particular condition, and to recommend further evaluation or follow-up testing if clinically indicated. Of course, remember to document any discussions with referring clinicians. Bear in mind that patients will have direct access to your reports (including via their My Health Record) so it is important to be consistent in your messaging and take care to avoid jargon or acronyms.
Missed and delayed diagnoses may not be entirely avoidable. They are much more likely however if the limitations of a particular test, or the need for ongoing monitoring, are not clearly articulated or understood by everyone involved.
Compensation claims and complaints insights – radiologists
View our infographic which identifies the main issues driving radiologist members’ compensation claims and complaints.
Our data highlights that claims and complaints against radiologists are fairly infrequent and it is not surprising the majority are related to diagnosis issues.
We also identified other issues that can give rise to claims and complaints, such as communication. In our experience, paying attention to communication with patients can help to reduce the likelihood of experiencing a claim or complaint.
For more information on diagnostic issues, communicating with patients and a wide range of other topics, visit the Avant Learning Centre, where you will find articles, factsheets, case studies, podcasts and many other resources.
If you receive a claim or complaint, contact us on 1800 128 268 for expert advice on how to respond, available 24/7 in emergencies.
- Claims refers to claims for money, compensation and civil litigation claims.
- Complaints relates to formal complaints to regulators.
- Matters include: claims, complaints, coronial cases and other matters such as employment disputes and Medicare.
- Employment disputes are matters where Avant defends members against complaints or supports members to resolve employment issues.
Note about data:
IMPORTANT: Avant routinely codes information collected in the course of assisting member doctors in medico-legal matters into a standardised, deidentified dataset. This retrospective analysis was conducted using this dataset. The findings represent the experience of these doctors in the period of time specified, which may not reflect the experience of all doctors in Australia. This publication is not comprehensive and does not constitute legal or medical advice. You should seek legal or other professional advice before relying on any content, and practise proper clinical decision-making with regard to the individual circumstances. Persons implementing any recommendations contained in this publication must exercise their own independent skill or judgement or seek appropriate professional advice relevant to their own particular practice. Compliance with any recommendations will not in any way guarantee discharge of the duty of care owed to patients and others coming into contact with the health professional or practice. Avant is not responsible to you or anyone else for any loss suffered in connection with the use of this information. Information is only current at the date initially published (July 2019).
For any queries please contact us at: email@example.com
This article was originally published in the Royal Australian and New Zealand College of Radiologists’ Inside News in December 2019.
1See for example Waite S, Scott J, Gale B, Fuchs T, Kolla S, Reede D. Interpretive Error in Radiology. AJR. 2017 Apr;208:739-749.
2Clinical Excellence Commission. Diagnostic Error: Learning resource for clinicians. Sydney: Clinical Excellence Commission; 2015.
3Department of Health. Canberra, ACT: National Dust Disease Taskforce. 2019 [updated 17 October 2019]
4Sparke C. CT scans advised for silicosis ‘health crisis’. 6 Minutes. 2019 Oct 14.