PI project needed ??

[Monty Python]

(Preface: I posted this in the Military Medicine forum, since this took place in a military facility. However I'm hoping it might generate productive discussion here as well. Thank in advance. Trin).

Today I attended the Patient Safety Committee. The chair (the hospital DCCS) wants to initiate a Process Improvement project to ameliorate one his pet peeves: providers not noticing or properly responding to incidental findings on lab and Xray reports. His case in point: a patient was sent to Xray for suspected AAA, which was confirmed on Xray. Xray report also contained the incidental finding of a small shadowing (nodule?) in the lung left lower lobe. Referring physician either didn't read or properly react to the incidental finding, wound up successfully fixing the AAA, and the pt died two years later from metastatic lung CA.

The DCCS wants a system created to "help the providers properly take note and respond to incidental findings." I'm thinking that's a primary professional responsibility of each provider, especially if the findings/values are properly annotated in the Xray/lab report. (note: I'm not talking about critical values which are called stat to the provider. I'm just talking about non-critical incidental findings).

Does anyone have a good idea (or experience) how this might be addressed at my small community hospital? The lab OIC in attendance says we're hamstrung by CHCS on this, and that any fix from her lane would involve IMD and software revisions. The hospital JCAHO readiness officer (acting chief of QM), who is also an RN, also feels this is a primary responsibility of each provider, and that any PI project would be very convoluted with too many moving parts. Thanks.

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[urge]

I think they should RLF the FKMLD before the board's HGRWA to avoid a XCR or any other FUBAR. However YMMV.

 

[Monty Python]

Sorry, forgot to translate the original post from military-ese into everyday English. Below is the original post with the acronyms spelled out.

Today I attended the Patient Safety Committee. The chair (the hospital Deputy Commander for Clinical Services, ie, hospital medical director) wants to initiate a Process Improvement project to ameliorate one his pet peeves: providers not noticing or properly responding to incidental findings on lab and Xray reports. His case in point: a patient was sent to Xray for suspected AAA, which was confirmed on Xray. Xray report also contained the incidental finding of a small shadowing (nodule?) in the lung left lower lobe. Referring physician either didn't read or properly react to the incidental finding, wound up successfully fixing the AAA, and the pt died two years later from metastatic lung CA.

The deputy commander for clinical services wants a system created to "help the providers properly take note and respond to incidental findings." I'm thinking that's a primary professional responsibility of each provider, especially if the findings/values are properly annotated in the Xray/lab report. (note: I'm not talking about critical values which are called stat to the provider. I'm just talking about non-critical incidental findings).

Does anyone have a good idea (or experience) how this might be addressed at my small community hospital? The lab officer-in-charge in attendance says we're hamstrung by the military electronic health record on this, and that any fix from her lane would involve the computer department and software revisions. The hospital JCAHO readiness officer (acting chief of Quality Management), who is also an RN, also feels this is a primary responsibility of each provider, and that any process improvement project would be very convoluted with too many moving parts. Thanks.