Filling the void: a low-cost, high-yield approach to addressing incidental findings in trauma patients

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Abstract

Background.

Incidental findings are prevalent in imaging but often go unreported to patients. Such unreported findings may present the potential for harm as well as medico-legal ramifications.

Methods.

A chart review of trauma patients was undertaken over a year. Systems-based changes were made utilizing our electronic medical record system and our staff protocols to improve the disclosure of clinically relevant incidental findings to patients.

Results.

During the preintervention period, 674 charts were reviewed. Trauma patients had a rate of incidental findings of 70%, and 36% of patients had clinically relevant incidentals. Rates of follow-up recommendation and disclosure to patients were 22% and 27%, respectively. In the postintervention period, of the 648 charts were reviewed, the rates of a clinically relevant incidental finding were 35%, but the rates of follow-up recommendation and disclosure to patients were 68% and 85%, respectively.

Conclusion.

Incidental findings are more prevalent herein than previously reported. With simple changes and minimal resources, clinically relevant and important improvement in reporting incidental findings can be made to mitigate the harm and medico-legal impact of an incidental finding going unreported.

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