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With the complexity of today’s healthcare environment, a pathologist may need to take a more active role in coordinating diagnosis communication than what may have been standard in the recent past. In the following case, the patient was never informed of a final diagnosis of malignancy after being informed the preliminary diagnosis was benign. Consider how the pathologists could have changed the outcome in this case.

It is a good idea to copy primary care physicians or physicians coordinating the patient’s care on pathology reports in addition to the physician who has obtained the specimen. A clinician who performs a biopsy and sends the sample to a pathologist may not otherwise be involved in the patient's care. If the pathology report is only sent to the clinician who performed the biopsy, an actionable diagnosis may never get to a physician who is in the best position to initiate or coordinate treatment.

In the following case, the pathologist’s finding was not listed on the urgent or unexpected diagnoses lists so she did not directly contact the ordering physician to report her findings. However, a number of experts in the malpractice suit that followed believed the pathologist should have done so. Consider how the outcome could have been different if the pathologist had used her medical judgment and focused on patient safety.

The final report is the definitive record of an imaging examination. Depending on the criticality of a finding, the radiologist may be required to directly contact the ordering physician prior to the report’s delivery. Different levels of urgency may require different methods of communication.¹

Often, when a patient comes to the ED, radiographic studies are interpreted by an on-site radiologist after the patient has been discharged or after the ordering ED physician has gone off shift. Consider how this outcome could have been different if the radiologist or ED staff had followed critical results policies and procedures.