Clinical Systems A major patient safety and risk issue is the availability of comparative studies. Two major reasons for films not being available include original films not returned to the center and prior films from other centers not provided to the center at the time of the new test. It goes without saying that digital archiving eliminates the factor of lost films. A large percentage of centers surveyed indicated that films are copied only sometimes prior to release. In addition, these centers do not verbally communicate to patients, nor do they include a statement in the signed acknowledgment form, indicating that the films are the property of the center and must be returned within a specific timeframe. Release of original films should be kept to a minimum. When release is necessary, patients should be informed of the importance of returning the films and sign an acknowledgment of such.   It is customary for radiology centers to request that patients bring previous studies with them from other centers for the radiologist to compare with current studies. It is understandable that patients may forget to pick up films from other centers to bring with them to your center on the day of their study. If your usual process is to call patients a day or so prior to their appointment, this is an opportunity to again inform the patient of the need to obtain the prior films. The gold standard of obtaining prior films if not provided to the center the day of the study is to implement a tracking system to follow-up with the patient and referring physician to obtain the studies after the study is completed. Attempts to reach the patient or physician by phone or mail should be documented, and copies of letters or postcards mailed should be retained. A PACS may have the capability to automate this workflow process.   When scheduled patients fail to show for their exam, they not only cause a workflow interruption but also an increased risk to the radiology center. A survey of insured radiologists indicates that many do not communicate patient no-shows to the referring physician. The optimal process would be to inform in writing to both the patient and referring physician that a no-show occurred, and the study should be rescheduled. A helpful tip is to engage the referring physician in following up with the patient as soon as possible to avoid potential delays in patient work-up with a letter such as:   Our records indicate you are the referring physician for the patient listed above. We have been tracking possible problems for this patient that were detailed on an ultrasound examination performed on 9/10/08 in which follow-up ultrasound was recommended. This letter is to notify you we have not been able to resolve this diagnostic follow-up as being complete due to patient cancellation (or no-show) for a follow-up study on 12/10/08. Your assistance to resolve this exam is required.   A PACS may have the capability to automate this workflow process through generation of no-show letters to the patient and referring physician. A formal mechanism should be created to identify and address all non-resolved studies. To assure that no study is left uninterpreted, a process should be established to identify any uninterpreted studies and for all radiologists to follow up in promptly interpreting them. In situations in which an entire study or key images are lost, or when images cannot otherwise be interpreted, the referring physician or the patient should be promptly contacted to schedule another study.   Documentation Since the majority of the communication with the referring physician is through documentation of the radiology report, inadequate reports can compromise care and increase your risk. Comprehensive documentation may improve patient outcomes and defense should an unanticipated outcome and ensuing claim occur. Make sure the documentation includes:   ·         Recommendations for further studies that include your indication (e.g. “CT may be helpful in staging, localization, or characterization”). Likewise, recommendations for procedures should also include your indication (e.g. “bronchoscopic biopsy, percutaneous needle aspiration or endoscopy may further differentiate the mass”).   ·         If applicable, reference that magnified views were reviewed in the interpretation.   ·         Limitations of study, such as “prior films for comparison were not made available by the patient.” Also document that the patient was again informed to obtain and provide the studies, if possible (e.g. may not be possible if lost).   If prior films are available and reviewed, comparison should be mentioned in the report. In digital systems, the capability readily exists for comparison. Documentation must reflect historical comparison. Otherwise it could be alleged that the radiologist is negligent if old digital images that are readily available were not taken into consideration.  ·         Direct impression and recommendation. Avoid vague statements such as, “if clinically indicated.” If you make a recommendation, document it clearly and include the indication.   Documentation of communication with other providers is critical. Assure there is a permanent record of the communication of the report to the ordering provider including date, time, and mode of transmission of the report. If reports are faxed, staff should check to see if the transmittal was successful and maintain a permanent record of the transmittal document.   Conclusion Careful attention to mechanisms to improve interpretation, communication, clinical systems and documentation can provide the greatest impact on patient safety and risk. As a team, staff and physicians can identify where potential failures may occur and design better, safer processes.