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Record error drift to IR
I just joined this forum today and finally have an outlet for a number of weird cases Ive come across in the last 1.5 years.
Question for IR: Have you ever found out that a deciding criterion for exclusion of a pt from mechanical thrombectomy was in reality a records or verbal reporting error?
Case in point, a night transfer pts CTA with obvious LVO was sent to on-call IR after the mid-level initiated a neuro consult. Neuro advised perfusion study and IR angio. Mid-level asked IR about angio with possible thrombectomy; IR declined on account of NIHSS 0. Last NIHSS 10 in pt record. Mid-level initiated conservative stroke protocol. IR decision forwarded to neuro threw up flags when NIHSS was reported back with exclusion as 0. Mid-level never checked verbal report accuracy with records.
How does IR usually get clinical information at your facility? Word of mouth? Or digital records access? How do you deal with the issues of someone screwing up the information flow to you?
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2 Replies
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You sound like a lawyer fishing for information.
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I can see that interpretation.
In reality, Im an archives designer for Rad and IR research studies. I have to design exclusionary criteria for specific studies as well as records retrieval protocols for submissions that come from handwritten notes through closed digital systems. Right now were working on 1.5 years of data review for inclusion/exclusion to IR guided thrombectomy study.
One recurrent theme Im finding from specific pt courses is records drift error for pts who arrive at stroke centers from outside facilities being the ultimate deciding factor not to send or receive pts to IR lab.
I was a bit astonished at the prevalence, and was excited at a possible outlet/commiseration in discussion here.
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