Incidental Does Not Mean Insignificant

Description

Ordering providers were not informed of an incidental finding on a chest computer tomography (CT) scan, resulting in a delayed lung cancer diagnosis that ultimately metastasized and caused the patient’s death.

Key Lessons

• Incidental findings can easily be missed by ordering providers if they are buried in the details of the radiological exam report
• There should be clear policies and procedures for reporting and communicating incidental findings, particularly if they are deemed urgent

Clinical Sequence

A 65-year-old patient went to their primary care provider (PCP) three different times over four months, complaining of cough, chills, nocturnal sweats, sharp shoulder pain, shortness of breath, fatigue, and nasal congestion. They reported a history of smoking four packs of cigarettes per day for 30 years, diabetes mellitus, atrial fibrillation on coumadin, and a family history of lung cancer. They were treated with antibiotics and a nebulizer each time they presented. Because the patient’s lungs and chest X-ray were clear, the patient was diagnosed with anxiety.

A short time later, the patient presented to the ED with knee pain from a fall. Their international normalized ratio (INR) was elevated, so the patient underwent a CT scan of the brain, chest, and abdomen to rule out a bleed. The radiologist noted the presence of lung nodules and recommended further evaluation with a follow-up positron emission tomography (PET) scan and/or thoracic biopsy in the report. However, the radiologist did not put this incidental finding in the impressions or recommendations sections of the report, nor did they communicate the findings to the ordering provider or patient. Because the CT of the brain was negative for a bleed, the patient was discharged. The patient’s discharge papers, including all studies, were sent to his PCP.

Six months later, the patient presented to their PCP with chest discomfort and was sent to a specialist for another CT, which identified lung nodules. A subsequent lung biopsy confirmed a diagnosis of advanced lung cancer with metastasis. The patient died shortly thereafter.

Allegation

The radiologist failed to communicate a significant incidental test finding to the ordering provider, leading to a delayed cancer diagnosis.

Disposition

The case was settled in the high range (>$2M)

Clinical Analysis

• An incidental finding, although documented within the radiology report, was not mentioned in the summary section, nor were they communicated to the ordering provider
• The providers in the ED, being concerned with the potential for bleeding in the brain, focused only on the results of the brain CT rather than incidental findings in the full radiology report
• Certain findings should be considered urgent and verbally communicated to the ordering provider
• The report summary section should include the presence of an actionable incidental finding, recommended follow-up modality and time frame, evidence supporting recommendations if available, and documentation of any notification or communication¹

Discussion Questions

1. What protocols are in place for communicating urgent incidental findings?
2. When documenting incidental findings, where in the report are they found?

Resources

1. Best Practices in the Communication and Management of Actionable Incidental Findings in Emergency Department Imaging | Journal of the American College of Radiology
2. Analysis of Radiology Report Recommendation Characteristics and Rate of Recommended Action Performance | JAMA Network Open
3. ESR guidelines for the communication of urgent and unexpected findings | European Society of Radiology

This is a fictitious case that illustrates commonly encountered issues and is for educational purposes only. Any resemblance to real persons, living or dead, is purely coincidental.