Tag: addendum

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A Ridiculous Error In The Radiology Report: Can I Recover My Dignity?

error

At some point in our careers, we all make ridiculous report errors. In fact, I know several radiologists that collect and sort several of these “oopsies” in the hopes that one day they will create the book of their dreams. However, some of these mistakes can feel embarrassing if you are the radiologist writing the report. Worse than that, sometimes your referring clinician or patient will call you on it. It could be a simple error like an obscene typo. (the substitution of the word “fecal” for “fetus”!) Or, it could be a detail you would have never thought to mention but your clinician wanted to know. (He asked to rule out sphenoid sinus disease, and you forgot to mention the sphenoid!) Ultimately, these mistakes go on record for all the patients and clinicians. So, how do you deal with these unfortunate miscalculations? And what do you tell the clinician? As you can tell, we will answer these questions as we dedicate this post to the delicate unforeseen “oopsie” and subsequent attempt to recover your dignity!

The Three-Step Process When You Make An Error

Make A Quick Addendum

First off, luckily, you have discovered the error in the report. Perhaps, you read the old dictation or received a phone call from the secretary. Unfortunately, however, you often make the discovery a long time after signing it off. So, what do you do? Issue an addendum as soon as possible! In most clinical practices, addendums from voice recognition technology software typically get faxed to the clinician, just like the initial report. In this situation, the clinician will receive the addendum with the rest of the dictations for the day.

Guide The Doctor To The Correct Report And Follow-Up

However, issuing an addendum is not enough. Often, the clinician will not expect the fax you give as an addendum. Bottom line: it might not get read. And sometimes, the undiscovered “oopsie” may lead to inadequate follow-up, insurance problems, patient anger, or other subsequent clinical issues. Therefore, the rules of mutual respect obligate you to contact your referring physician directly by phone or in person, if possible. It’s a horrible phone call, but you must close the loop.

Profusely Apologize For The Error

Although a touchy subject, I would recommend apologizing to the clinician (or patient if necessary) for the error. More importantly, let the receiver of the error know that you have made amends by changing the report and following up with the report recommendations. Most clinicians will appreciate your effort to correct the issue with the dictation.

Can You Recover Your Dignity From An Error?

Unfortunately, I can’t give you a better answer than it depends. For ages, some may refer to you as the clinician who added a ridiculous mistake to their patient’s report, potentially giving you an unwarranted reputation. On the other hand, others will realize that you made the error as a “one-off” and will quickly forget. Regardless, we need to negotiate these pitfalls as the hazards of our profession. And most importantly, we are more likely to garner respect from our colleagues by dealing with the consequences of the “oopsie” head-on rather than lurking in the shadows, hoping the error will go away one day. So, don’t just ignore the error, so you don’t draw its attention. Instead, own your mistakes before they own you!

 

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The Art And Science Of The Lowly Addendum

addendum

Oh, the lowly addendum. Most physicians rarely give it a second thought. But, it can sometimes become the single most crucial part of the dictation. So, why do most of us ignore the addendum? And, yet how can it be one of the essential parts of our report simultaneously? Well, that is today’s topic!!! So let’s delve into the legal, medical, and ethical implications of the lowly addendum.

The Lowdown On The Lowly Addendum

OK. I will be the first to admit that the addendum is not the most exciting part of a dictation. Who wants to read that you discussed a case with physician x at time y on floor z? And, who cares that you had to add a correction to your dictation that seems so minor. But, there is so much more to the addendum. Let me show you below…

Addenda And The Legal World

First and foremost, the addendum is often the only part of the dictation that can protect us from a lawsuit. Many addenda incorporate a time, place, and person after we discuss a case with a clinician. Usually, we place it after the “final dictation.” Sometimes it is the only documentation in the chart that the radiologist took the time to give the caring physician the report results.

On the other hand, when the addendum is absent in the case of a serious diagnosis and the patient encounters severe morbidity, we leave ourselves open to the legal system. Who is to say that the clinician looked at the report results on your patient with appendicitis? It is only the supplement that documents this vital information.

When Absence Of An Addendum Is Legally Important

Ironically, the absence of an addendum can also protect the radiologist. If you write addenda on a routine basis every time you discuss a case with a clinician, then when you don’t write a supplement, a communication never occurred.

How is that important? Well, let me give you an example: You have just dictated a normal case on a pediatric chest film with a history of shortness of breath. And, the clinician states that they discussed the case with you. On the deposition, he claims that he told you about the possibility of child abuse on this patient and that you told them not to order a leg film to look for a fracture. Since the physician did not request the test at your hospital, it turns out the patient went to another hospital for additional imaging three days later with a positive study for a leg fracture. Perhaps, the fracture did not set correctly. Well, if you did not document the discussion with this clinician, it never happened (unless the other physician can prove otherwise). It is no longer your fault that the clinician did not order the correct test in your hospital!

Addenda And The Medical Record

Addenda can also be necessary for determining the order of events during a patient stay. At times, a nurse may poorly document the time of events crucial to determining a diagnosis for the patient. Documentation of communication in an addendum can help to clarify when events occurred. Theoretically, it can differentiate the cause of a disease/illness.

Alternatively, frequently we will issue a supplement as a correction to our dictation. Sometimes, we may see a finding we may not have documented in the “final report.” Placing an addendum, in this case, becomes medically essential. If a clinician looks back and does not see, for instance, a sclerotic bone lesion in your report, they may not know that it exists. The treatment can potentially change, leading to poor patient care. On the other hand, if you issue an addendum and communicate the results, you protect the patient (in addition to yourself!).

Or maybe, you made a typo in the history and said the patient had a history of breast cancer versus the true history of prostate cancer. Believe it or not, this can have significant implications for insurance companies reimbursing a patient for the imaging study. A lousy history can lead to a denial of care payment for a patient. An addendum as a correction can be a lifesaver for this patient. It is very frustrating to have to deal with denial of care payment issues when you are sick!!!

Ethical Obligations To The Addendum

We, as physicians, are ethically obliged to abide by our Hippocratic oath to do the best for our patients and do no harm. Based upon some of the examples above, we fulfill a moral and ethical imperative to improve patient care by creating addenda. So even though overlooked by our readers, we need to be vigilant about reporting addenda when necessary. Don’t forget about the lowly addendum!!!