Business of Medicine | Incidental Findings in Cardiac Imaging: Clinical Opportunity or Legal Liability?
Advances in cardiac imaging technology are leading to increased detection of incidental, noncardiac abnormalities within scanned areas.1,2 Pulmonary nodules are one of the most common incidental findings.3 If the ordering practitioner does not follow up, an incidental finding may lead to patient harm and result in a malpractice claim.4
Case Example
The estate of a patient alleged the patient's death was due to the failure to follow up on the results of a coronary computed tomography angiogram (CCTA) that reported suspicious lung nodules. This resulted in a two-year delay in the diagnosis and treatment of lung cancer. The named defendants were the radiologist, two cardiologists, the cardiologists' respective groups, and two physician associates (PAs).
The established patient presented to their primary cardiologist's office with complaints of chest discomfort. The patient's history was notable for coronary artery disease, hypertension, hyperlipidemia and metastatic squamous cell carcinoma of the neck. The patient saw the PA, who ordered a CCTA. As is standard, the thoracic portion of the scan was also reviewed, and a radiologist performed an overread. The radiologist's impression included two suspicious nodules in one lower lung lobe. The recommendation was for further evaluation with positron emission tomography (PET)/CT scanning. The radiologist added the report to the ordering PA's electronic in-basket, per protocol, but did not make a direct phone call to the PA or the primary cardiologist regarding these findings.
The interventional cardiologist noted the CCTA arterial findings without mentioning the lung nodules. This CCTA report was also placed in the PA's electronic in-basket for review and follow-up.
Neither report was seen by the ordering PA. In deposition, the PA stated they were unaware they had an electronic in-basket for incoming test results and assumed, since they only worked part-time, that test results were being routed to the primary cardiologist for review and follow-up.
The day after the CCTA, the primary cardiologist saw the patient, discussed the coronary findings, and recommended a cardiac catheterization to further evaluate the severity of disease. The primary cardiologist did not mention the lung nodules at this visit, nor was there any documentation of the nodules in the cardiologist's notes.
One week later, the patient underwent cardiac catheterization and was found to have mild to moderate multivessel coronary artery disease. Three weeks later, during the patient's follow-up visit, a second PA reviewed the catheterization findings and the prior CCTA, but did not document review or follow-up regarding the lung nodules.
The primary cardiologist and PAs saw the patient periodically over the next two years, until a chronic cough prompted a chest x-ray that revealed the same lung nodules. A diagnosis of squamous cell lung cancer was made, but the disease had progressed, and the patient died six months later.
The case was settled, on behalf of both the primary cardiologist and the PA who ordered the CCTA, for failing to act on the incidental findings.
Case Discussion
The plaintiff alleged that all defendants deviated from the standard of care by failing to timely recognize and follow up on the lung nodules noted in the radiologist's CCTA report.
Defense experts supported the care of the radiologist, interventional cardiologist and second PA. However, they were critical of the ordering PA and the primary cardiologist for not recognizing and following up on the incidental findings.
There was a system failure, including a lack of tracking and reconciliation of pending test results.
Risk Management Strategies
The following strategies can help practitioners improve their quality of care, decrease patient harm and reduce the risk of malpractice litigation.
- Test Result Tracking Systems: Implement closed-loop communication systems to track all ordered tests and results. Assign responsibility and develop safety-net mechanisms to ensure follow-up on abnormal and incidental findings. Document the receipt and review of incidental findings, patient notification and next steps. Consider the use of artificial intelligence to assist with identifying, tracking and managing follow-up of incidental findings.5
- EHR Training and Documentation: All practice staff, both clinical and nonclinical, must undergo structured onboarding with validated EHR training, including test result workflows and inbox responsibilities. Standardize documentation for incidental findings. Perform periodic audits to ensure that documentation is complete for incidental findings, including identification, actions, referrals, patient notification and responsibility for continuing care.
- Advanced Practice Providers (APPs): Follow state laws governing the practice of APPs (such as nurse practitioners [NPs] and PAs), including those related to scope of practice, prescriptive authority and physician responsibility for supervision, collaboration and practice agreements if required. Review APP documentation for quality improvements. Emphasize the role of continuing education and assessment. Structured competency assessments6 and knowledge examinations for NPs and PAs, such as ACC's NP/PA Certified Cardiovascular Knowledge Examination (CCKE), support high standards among APPs. The CCKE covers interpretation of studies, recognition of incidental findings and follow-up care planning – skills directly relevant to this case.
This article was authored by Amy Brownell, MSN, FNP-C, FACC, director of the Cardiovascular Service Line, Ascension Illinois, Chicago, and Debra Davidson, MJ, CPHRM, CPPS, senior patient safety risk manager for The Doctors Company, Napa, CA. Both are members of ACC's Medical Professional Liability Insurance Workgroup.
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.
References
- MacMahon H, Naidich DP, Goo JM, et al. Guidelines for management of incidental pulmonary nodules detected on CT images: from the Fleischner Society 2017. Radiology 2017;284(1):228-243. doi.org/10.1148/radiol.2017161659
- Sripariwuth A, Kruamak T, Xu B. Contemporary review: a clinically oriented interpretation of incidental radiological findings for common cardiovascular computed tomography scans. AME Medical Journal 2022;7: doi:10.21037/amj-21-30
- Langan RC, Goodbred AJ. Pulmonary nodules: common questions and answers. Am Fam Physician 2023;107(3):282-291. Available here.
- Ross J, Jordan A. Detecting and addressing incidental findings: medical malpractice claims. The Doctors Company. 2024. Available here.
- Lubell J. How Geisinger uses AI to ensure incidental findings get follow up. American Medical Association News. Dec. 20, 2023. Available here.
- 2020 ACC clinical competencies for nurse practitioners and physician assistants in adult cardiovascular medicine: a report of the ACC competency management committee. J Am Coll Cardiol 2020;75(19):2483-2517. https://www.jacc.org/doi/10.1016/j.jacc.2020.01.005
Clinical Topics: Cardiovascular Care Team, Noninvasive Imaging
Keywords: Cardiology Magazine, ACC Publications, Missed Diagnosis, Delayed Diagnosis, Incidental Findings, Malpractice, Physician Assistants, Delivery of Health Care, Computed Tomography, Liability, Legal, Cardiac Imaging Techniques
