Central PA Medicine Fall 2017 - 35

daup h i n c m s .o rg

Dr. Michael A. Bruno, Chair of the Radiology
Quality and Safety Committee and then Director
of Radiology Quality & Safety, conceived of an
innovative plan. He decided to use the patients
themselves as messengers to deliver our follow-up
recommendations to their own PCP since they
are the ones who are the most invested in the
information. Thus, Project Failsafe was born.
'Project Failsafe' is an effort to reduce the harm
from overlooked incidental findings using
the patient as a messenger to assure that the
radiologists' recommendations actually reach
the appropriate primary care physician.

long term health, and they even agreed to accept
any Failsafe patients who lacked a PCP into the
Penn State Family and Community Medicine
practice. The ER physicians noted that the final
radiology report arrives by the time the patient
has left the ED, leaving them wondering what to
do about incidental findings that are of uncertain
significance, or that are not serious enough to
recall the patient but nevertheless should be
eventually addressed. The hospital quality side
leadership agreed that it was an important patient
safety issue, and fully supported the cost of the
program from its outset.

Emphasizing the need for the program, Dr.
Bruno said that "Patients often have a wrong
impression that when they go to the ED, they
have been thoroughly evaluated by a physician,
so they don't need to visit their PCP after an
ED visit. They don't realize that ED physicians
provide only acute management and treatment
of the urgent condition which brought them
to the ED."

The initial days
After sending out the first 100 letters, Dr
Bruno telephoned a sample of patients to gauge
the response which was very encouraging. But
later, after letters had been sent to over 500
patients, a repeat phone survey conducted was
disappointing. Most patients said they weren't
concerned about the letter. Some had torn it up
assuming it was about their bill, some thought
the doctors already knew about it and threw it
away, while others read it but did not think they
needed a follow up.

Under 'Failsafe', radiologists identify cases
where there are incidental findings unrelated
to the ED visit and which require non-urgent
or delayed follow up. In these cases the Patient
Safety Department sends the patient a letter on
behalf of the Department of Radiology, signed
by Dr. Bruno, informing them of the radiologists'
concern that they may need follow-up of an
incidental finding, and urging them to visit their
PCP for further evaluation.
Due to privacy and legal concerns, the letter
itself is quite generic and just says that their
radiology report contains some significant
findings not related to their ED visit and requests
the patient to take the letter to their PCP for
further discussion. There is a separate letter for
adults and children and letters are available in
English or Spanish.
Guaging the support
The Failsafe plan was designed in cooperation
with ER physicians, PCPs, hospital quality and
safety officers, hospital administration, and
attorneys from the Penn State Office of General
Counsel. Two department chairs were involved
from the outset (Radiology and Emergency
Medicine). The PCPs strongly supported the
plan since they could see it benefitting the patients'

Expanding/modifying the program
We interpreted this as a problem of patient
engagement. After some deliberation, at the
behest of Dr. Bruno, the committee unanimously
decided to hire a nurse, not only to mail out
the letters but also make phone calls to patients
to ensure they received the Failsafe letter and
encourage them to contact their PCP.
Accordingly, in early 2016, Nicole Seger,
MSN, RN, CPN, a nurse patient safety analyst,
was hired by the Department of Patient Safety
to administer the Failsafe program. She now
contacts all failsafe patients by phone after
sending their letter.

contacted by phone; 21% of the latter planned
to see their PCP to discuss the letter. 70% of
patients contacted by Nurse Seeger acknowledge
that they came to know about their incidental
findings only when they received a phone call or
received our letter.
To our knowledge, our project is the first of its
kind using the patient as a messenger to deliver
radiologists' follow up recommendations to the
PCP, although other centers have also found
ways to address this critical issue. For example,
the Massachusetts General Hospital (Boston)
is trying to reliably find ways to communicate
incidental findings directly to patients while
they are still in the ED, or have an ED nurse
call them after discharge to apprise them of the
need for follow-up. The University of Chicago
is working on a "three strikes" system to track
and motivate referring doctors to follow-up on
incidental findings using an automated system
embedded in their RIS-PACS and electronic
medical records systems. Under this plan, which
is run by the Department of Radiology, they first
remind doctors via an electronic alert to follow
up on significant incidental findings, followed
by a second electronic reminder copied to the
Department chair if the first step fails, and lastly
with an electronically-generated letter sent directly
to the patient and their PCP of record, if the first
and second methods fail.
The Bumps
Everything has not been easy. There have been,
especially in the early days, angry phone calls
from physicians asking why patients are being
encouraged to bother them, and phone calls and
even personal visits by patients to the radiology
department asking for explanation of their
letter. But we are confident that our program is
preventing patient harm and is worth the trouble.

Future
Encouraging results
While data is being studied to better assess
A memo was sent out via the medical staff office the full impact of the program, we have very
to apprise everyone in the Hershey care community recently expanded the Failsafe program beyond
about the program, which has been well-received the ED to include all HMC radiology patients.
by the full medical staff. Most patients also have The ultimate aim is to prevent incidental findings
said they appreciate the calls and the conversation falling through the cracks and thus to keep our
has motivated them to follow-up with their PCP. patients safer.
In the past 6 months, letters have been sent out
to 106 ED patients and 48 of them have been

The author thanks Dr. Michael Bruno, Penn State Health,
and Nicole Seger, RN, MSN, for providing information and
statistical data for the article.
Central PA Medicine Fall 2017 35


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