36C25719R0002-000.pdf

DEPARTMENT OF VETERANS AFFAIRS

NORTH TEXAS HEALTH CARE SYSTEM

DALLAS, TEXAS

RADIOLOGY SERVICE

February 2, 2017 549/114

RADIOLOGY SERVICE POLICY AND PROCEDURE: NO. 114-17

REPORTING CRITICAL RADIOLOGIC TEST RESULTS

1. POLICY

Radiology Service defines critical radiologic test results and ensures compliance among staff with the VANTHCS Medical Center Memorandum 00-09, Reporting of Critical Test Results (MCM 00-09) on the policy and procedures for reporting critical results.

2. DEFINITIONS

Critical Test Result - A test result that is beyond the normal variation with a high probability of a significant increase in morbidity and/or mortality in the near future. This may include, but is not limited to:

(1) Any finding that has the potential to be life threatening or could cause serious harm and that requires an urgent intervention or change in patient management (i.e. pulmonary emboli, deep venous thrombosis);

(2) Any finding that might result in prolongation of patient pain or discomfort, if known to the radiologist (i.e. acute fracture);

(3) Any finding that would result in the cancellation of significant on-going or imminent treatment, if known to the radiologist;

(4) Specific conditions:

1. Pneumothorax

a. Acute tension pneumothorax

2. Intracranial hemorrhage

3. Ruptured aneurysm

4. Leaking aortic aneurysm

5. Aortic dissection

6. Occlusive intracranial stroke

7. Foreign object

a. post surgical foreign object

b. depends on location and object

8. Ectopic pregnancy

9. Free air peritoneum

10. Testicular torsion

11. Deep venous thrombosis

12. Acute hemorrhage

a. Hemothorax

13. Life threatening cardiovascular/respiratory problem/pulmonary emboli

14. Life threatening neurological problem

15. Significant skeletal muscular/vascular injuries

16. Vertebrae fracture unstable

17. Perforated viscus

18. Bowel obstruction

19. Spinal cord compression

20. Incorrect location of venous access, catheter or tube (ET tube)

21. Possible tuberculosis

22. Any other condition determined by radiologist as requiring immediate intervention for treatment.

Read-back Process - The read-back process is a process of verifying critical test results.

The individual who is receiving the result will write it down and then read back what they have been told and receive confirmation that it is correct.

3. RESPONSIBILITY

Radiology Service Chief:

1. The Radiology Service Chief is responsible for instructing staff regarding policies and procedures for communication of critical test results and developing a process to monitor compliance.

Radiologists:

1. Radiologists are responsible for complying with this policy on critical radiologic test results as well as the policies and procedures stated in MCM 00-09.

2. Critical findings require urgent attention and will be immediately and directly communicated to the ordering physician or their surrogate. Direct communication consists of a face-to-face or telephone conversation. The time and means of such communication, and the name of the person contacted, will be entered in the electronic medical record either as a note or within the study report.

3. In additional to verbal communication, radiologists will ensure all reports are properly coded with an appropriate diagnostic code/view alert. For tracking for all critical findings.

4. All Imaging studies performed at this facility will be entered and verified in the electronic medical record.

Ordering Physicians:

1. Responsible for placing the initial order with appropriate contact information, preferably a valid beeper number for themselves and their surrogate if applicable.

2. Taking responsibility for the results of any orders that they have placed.

3. All Imaging studies to be performed at this facility will be ordered electronically.

Orders will not be accepted unless they include an indication for the study, the name of the ordering physician and contact information, including a pager number.

Ordering Services:

1. Services ordering radiology exams are responsible for designating a surrogate physician to accept critical results if the ordering physician is unavailable.

2. They are also responsible for taking appropriate follow-up action based on critical test results reported to their physician.

4. PROCEDURE

Radiology Service will follow the procedure for reporting critical test results as outlined in VANTHCS Medical Center Memorandum 00-09, Reporting of Critical Results.

5. REFERENCES

VANTHCS Medical Center Memorandum 00-09, Reporting of Critical Results

Joint Commission for the Accreditation of Hospital Organizations (JCAHO) Manual for Hospitals, updated edition.

ACR Standard for Communication: Diagnostic Radiology

6. RESCISSIONS:

Reviewed by: Robert Sims, Radiologist, Radiology Service, February 2, 2017

Prior Revision by: Michael I. Ginsburg, M.D., Chief of Radiology Service, May 3, 2010.

Approved by: Michael Ginsburg, M.D., Chief of Radiology Service, February 2, 2017

Michael Ginsburg, M.D.

Chief, Radiology Service