Development of the Radiology Investigation Guide: The Coronial Perspective

1. Development of the Radiology Investigation Guide: The Coronial Perspective Megan Bohensky Research Officer Clinical Liaison Service

2. Missed Radiology Case Study • 85 year old male MVA. Arrived in the ED of a Melbourne Hospital. • Injuries that included lacerations to his head, nose, and left shoulder, and neck soreness. • Radiographs and CT scan to head and neck revealed no abnormalities. Discharged later that day to be driven home.

3. Missed Radiology Case Study • HMO who saw the deceased in the ED reported no loss of consciousness and normal vital signs. • CT scan of his cervical spine was verbally reported as being normal by the on-call radiologist. • The CT scans were routinely reviewed the following day when a second radiologist reported a potentially unstable fracture of the second cervical vertebra. • Hospital contacted the patient’s GP the following day reporting the unstable spine fracture that was identified. • Patient returned to hospital, developed cardiac arrhythmias. Died sixteen days after his accident.

4. Missed Radiology Case Study…. The Inquest • The initial verbal, or interim, report was not documented by the first radiologist and was therefore not available for other clinicians to read. During the inquest, this radiologist had no recollection of the case. • The process of radiological reporting and communication with the emergency department was considered the major discussion point during the inquest.

5. Objectives • Factors Influencing the Development of an Investigation Standard • Using the Coronial Process to enhance Healthcare • Development of an Investigation Standard • Description of the Standard • Steps Taken

6. Medical Adverse Events are a Problem • Harvard Medical Practice study revealed that 3.7% of US hospitalizations result in a medically-incurred injury, 13.6% of which lead to death. • United Kingdom, researchers found that 10.8% of the hospital admissions reviewed in their sample were associated with a medical error and approximately 8% of these patients died as a result. • Quality in Australian Health Care Study (QAHCS)approximate that 16.6% of hospital admissions in Australia were associated with preventable adverse events and 4.9% lead to death. Extrapolation of this data • As many as 3,000 iatrogenic injury-related deaths may occur in Victoria per year!

7. Coronial Process for Quality Improvement in Healthcare? • Internal audit systems • Inconsistent acceptance of reported deaths • Lack of clarity regarding Inquest Process • Limited specialist medical analysis of issues • Trial by media

8. Factors influencing Development of Standard Investigation • Difficulties arise when medical cases are investigated in the coronial setting due to the contrasting specialist knowledge used in legal and medical practice • Variations in approach and practice occur between investigators, resulting in inconsistent findings

9. Factors influencing Standard Investigation • The lack of medical input and disparate frameworks have led to difficulties including • Delays with investigations • Inconsistent findings • Inappropriate recommendations. • Legal profession has traditionally used case law which results in an ad hoc review • Many of these have failed to detect clear instances of medical error.

10. Harvard Malpractice Study5 • Legal claims correlate poorly with incidences of adverse events • Of 46 finalised malpractice claims • 10 of 24 - identified as involving no adverse event were settled for the plaintiffs (mean payment, $28,760) • 6 of 13 - cases classified as involving adverse events but no negligence (mean payment, $98,192) • 5 of 9 - cases in which adverse events due to negligence were found in our assessment (mean payment, $66,944). • Seven of eight claims involving permanent disability were settled for the plaintiffs (mean payment, $201,250).

11. Coronial Investigation • In a study on Road Traffic Fatalities, 5% (14) deaths were determined preventable (Patient who were considered to have a greater than 75% chance of survival given optimal medical management.) • In 6 cases, the Coroner’s finding made no mention of any medical treatment having been provided at all • In 7 cases, the Coroner’s finding included only a brief summary of the clinical course and nothing regarding its quality. • (These findings did not include any statement to the effect that the treatment had contributed to the death.) • Several commented on the excellent quality of the treatment!

12. Coronial Investigation • In only ONE case did the Coroner address in any detail the problems that occurred during medical treatment; – The finding was a 15 page document. • The key area of concern was obstruction of a tracheostomy tube. (The confidential medical review agreed that this was a major failure of medical care that substantially caused the death.) • Even though these issues were apparent to clinical medical experts, the coroner concluded that the medical treatment did not contribute to the death. • (The Clinicians themselves agreed that it caused it !)

13. Factors influencing Investigation Guide • Experience in Hospitals has shown that Practice Guidelines, when used as a quality-of-care tool, can help to influence: • Completeness • Consistency (decreasing variation in practice) • Simplicity2 • Proactive • Can Engage Stakeholders

14. The Radiology Investigation Guide • Patient’s clinical course • The radiological examination(s) and surrounding events • The organisation’s system for monitoring the use of the radiology service • Relevant equipment or work practice

15. Process for Developingthe Investigation Guide • Identifying and defining a key area • Involvement of an interdisciplinary group to identify essential information • Dissemination and Implementation of the guidelines • Evaluation and Revision

16. Identifying and Defining a Key Area • Falls Investigation Standard • Missed Radiology results resulting from system errors Both are well-acknowledged and significant quality of care issues in Australia and internationally. Cases involving hospital care also represent an onerous workload for the Coroner’s court

17. Interdisciplinary Group to Identify Essential Information Three meetings were held at the VIFM to discuss the format and content of the Investigation Standard. Representatives from: • RANZCR • Monash Medical Centre • RACS • RACP • State Coroner’s Office • Clinical Liaison Service • Peninsula Health • Maroondah Hospital / RCH • RANZCR • ACEM • Royal Melbourne Hospital

18. Implementation of the Guidelines Evaluation and Revision • Guidelines will be implemented this year. • An evaluation will occur to determine the effectiveness of the standard and respond to any feedback. • A review of the guidelines will occur at this time.

19. Conclusion • The Investigation Standard was developed to create a consistent and proactive approach to manage the investigation of mis-communicated of radiology results • It is intended to use the Coronial Process for the purpose of enhancing Healthcare • The Radiology Investigation standard was developed with input from stakeholders in healthcare and will be reviewed on a regular and ongoing basis.

20. Thank You! • Localio AR, Lawthers AG, Brennan TA, Laird NM, Hebert LE, Peterson LM, Newhouse JP, Weiler PC, Hiatt HH. Relation between malpractice claims and adverse events due to negligence. Results of the Harvard Medical Practice Study III. New England Journal of Medicine. 1991 Jul 25;325(4):245-51. • Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. British Medical Journal. 2001 Mar 3;322(7285):517-9. • Wilson RMcL, Runciman WB, Gibberd RW, et al. The Quality in Australian Health Care Study. Medical Journal of Australia 1995; 163: 458-471. 4) Merritt TA, Palmer D, Bergman DA, Shiono PH.Clinical practice guidelines in pediatric and newborn medicine: implications for their use in practice. Pediatrics. 1997 Jan;99(1) 5) Brennan TA, Sox CM, Burstin HR. Relation between negligent adverse events and the outcomes of medical-malpractice litigation.N England J Med. 1996 Dec 26;335(26):1963-7.