Massachusetts General Hospital Focuses on Radiographic Scans to Improve Patient Safety

By Christopher Cheney

Massachusetts General Hospital has launched an innovative patient safety initiative to promote the timely communication of radiographic results.

Patient safety is a top priority for CMOs. Patient safety concerns at health systems and hospitals include healthcare-associated conditions such as infections and medical errors.

“As CMO, I believe there is no higher priority than patient safety and the culture we build around it,” says William Curry, MD, CMO of Massachusetts General Hospital, Massachusetts General Physicians’ Organization, and Mass Eye and Ear.

Massachusetts General Hospital, which is a part of the Mass General Brigham health system, recently established a policy and process for the acknowledgment of clinically significant radiographic results, Curry says.

“A well-known issue in patient safety internationally is communicating results of scans to the appropriate responding clinician and closing the loop so you know that the responding clinician knows about critical or unexpected results,” Curry says.

For example, a doctor may have a patient in the office on a Friday and be worried about pneumonia. A chest X-ray or CT scan is ordered for Saturday morning. While there may be pneumonia identified on that scan, there may also be something else identified such as a pulmonary embolism, which is an emergency.

Massachusetts General Hospital is setting up a system that is resilient to confirm that the ordering clinician or whomever is covering for that clinician gets results promptly. Subsequently, one of the clinicians can carry out the right action for the patient.

Massachusetts General Hospital has created the technology infrastructure for radiologists to reach out and get closed-loop responses from clinicians whether the situation is emergent or important, Curry adds.

“We also require Epic-based documentation of the receipt of scans by the responding clinician within 30 minutes to two weeks, depending on the urgency of the scenario and the need to protect the patient,” Curry says. “Once the ordering clinician acknowledges receipt of a scan, the next step is to make sure the appropriate action is taken and documented.”

According to Curry, there should be no patients who have had an image with an urgent, critical, or surprising result where the entire loop between acknowledgment of receipt of the scan and appropriate clinical follow-up is not carried out and documented.

“This is an exciting initiative, and it takes some of the burden off providers who worry about what they are missing,” Curry says. “The goal is to make a system for managing images that is more resilient than anything we have done before.”

Promoting a culture of safety

Massachusetts General Hospital’s patient safety philosophy is to be relentlessly patient-oriented, according to Curry.

“We want to create patient safety systems that are resilient to make sure that we are putting our providers in the best position to use their knowledge and their skills to deliver the safest possible care,” Curry says. “The key for us is to be relentlessly focused on every step of the patient journey to create the systems that prevent safety events from occurring.”

Curry and other hospital leaders are constantly showing that patient safety is a priority.

“We consistently message about patient safety and put it first in our communications,” Curry says. “We open every meeting with an assessment of patient safety. We review patient safety events at the institution as broadly as we possibly can—we are responsive to every patient safety event. We almost beg for reporting—there is no amount of patient safety event reporting that is too much.”

The health system uses RLDatix‘s RL6 patient safety reporting platform.

“We share patient safety reporting throughout Mass General Brigham,” Curry says. “We can learn from each other in an immediate way. If there is a safety event that occurs at Massachusetts General Hospital, the other hospitals in our health system can learn from our analysis of the event in real time.”

There are as many as 27,000 patient safety events reported at Massachusetts General Hospital annually. “We revel in the high number of safety events that are reported,” Curry says.

RLDatix recently announced the creation of the RLDatix Safety Institute, and Curry hopes the vendor partner will help Massachusetts General Hospital improve patient safety performance.

“I hope the RLDatix Safety Institute can help us address the known and the unknown issues in patient safety,” Curry says. “We learn from a volume of events, and we learn from each other. There is no single patient safety issue in particular that I am hoping to learn about from the safety institute—I am eager to see what kind of data they generate.”

Christopher Cheney is the CMO editor at HealthLeaders.