Page 25 - 2022 Risk Basics - Radiology

SVMIC Risk Basics: Radiology

city. Due to inaccurate information, the radiologist was under the

impression that the hernia repair surgery occurred on the same
date that the CT was performed. The radiologist read the CT scan

as having free intra-abdominal air, related to recent (within hours)
abdominal surgery, along with free fluid and some stranding, mild

fluid density scattered through the mesenteric fat. The patient
ultimately succumbed to the complications from his surgery. A

malpractice suit was filed against the surgeon and the radiologist.
Upon expert review of the radiology care, fault was found with the

radiologist in the interpretation of the CT scan. There was a large
amount of fluid, free air, and dilated air fluid loops of small bowel

that were inconsistent with findings even occurring on the same
day postoperatively.

Fault was placed with the radiologist for obtaining an inaccurate

history resulting in a negligent interpretation of an abdominal CT

scan.

Key Challenge #2: Documentation

Good recordkeeping is an integral part of patient care and malpractice

defense. The diagnostic specialty of radiology is not immune to this, and
it must be recognized that documentation should extend beyond the

confines of the radiology report.

The radiology report is the radiologist’s primary form of medical
recordkeeping, whether it be a diagnostic report or a written report
of a procedure. As earlier stated, it serves the dual purposes of

communication and documentation. This can take the form of a

handwritten report in the patient notes or, now more commonly, in
an electronic report. This electronic report is then stored on the RIS.

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