Diagnostic and Interventional Radiology Case Studies
Healthcare5 Case StudiesUpdated Sep 2026
This set of five case studies follows the work of diagnostic and interventional radiology teams in community and regional hospitals. The cases are drawn from fictional services and are built around the decisions that surround imaging rather than the images themselves: when to escalate, how requests are prioritized, what gets handed over between shifts, how capacity is rationed, how services measure their own performance, and how difficult conversations with patients are handled. Work through them in order, since later cases return to people and systems introduced earlier.
Case Study 1
Abdominal pain that kept returning to the emergency queue
Oldmere Valley Hospital, a 230-bed regional acute hospital with a single emergency department and a shared imaging suite serving two outlying clinics.
The situation
Ruth, in her sixties, first presented to the emergency department on a weekday evening with lower abdominal discomfort and a fever that settled within a few hours. Triage recorded the complaint, observations were within the usual range, and she was discharged with advice to see her own physician. Three days later she returned with worsening pain and a raised heart rate. An ultrasound was requested from the acute imaging list, and the radiologist reported a collection that needed same-day review. The phone call went to the emergency registrar, but the written report was filed against her earlier visit, so the urgent flag stayed invisible on the department board for most of the afternoon.
The challenge
The team had to decide how much weight to give a patient who had already been reassured once, whether the phone call counted as communication of a result, and who owned the follow-up when the report and the visit record did not match. The radiologist had done what the reporting standard required, and the registrar had received the call, yet nobody on the floor held the complete picture. The protocol for urgent findings had a clause about direct communication that no one had reread since it was introduced.
Analysis
Start with what Ruth needed at each contact. At the first visit the presenting picture was reassuring enough to justify discharge, and nothing in that decision was careless on its own terms. The second visit changed the evidence: a raised heart rate, persistent pain and an imaging result that described a collection requiring prompt review. Those findings are not a diagnosis, but they are a signal that the initial reassurance no longer held. Teams grounded in Diagnostic and Interventional Radiology usually begin by separating what the patient needs from what the record says she needs, because a visit flagged as routine can quietly carry a result that is no longer routine.
The protocol question is where the team's options become concrete. Most local urgent-result policies require a named clinician to receive the finding directly, record the time of receipt, and confirm that the receiving clinician has accepted responsibility for the next step. In this case the phone call satisfied part of that requirement, but the written report was linked to the wrong encounter, so the department board and the handover sheet never reflected the flag. Escalation is not only about reaching a senior colleague. It is about making sure the flag sits with the person who will act on it, in the system where the next shift will look.
- First attendanceReassuring observations, discharge with advice to see her own physician.
- Three days laterReturn with worsening pain and a raised heart rate.
- Imaging requestedUltrasound ordered from the acute list; collection reported as needing same-day review.
- Phone call loggedRegistrar informed, but the written report was filed against the earlier visit.
- Flag found by chanceFound by chance on the board after most of the afternoon had passed.
Actions taken
- Audit the last quarter of urgent imaging reports for results linked to a different encounter from the one in which they were ordered, and confirm each reached a named clinician.
- Add a required field to the urgent result template that records the receiving clinician's name, the time of receipt, and the encounter number, so the report cannot be filed without all three.
- Rewrite the emergency department return-visit checklist so that any patient returning within a set window with an abnormal observation triggers a review of imaging ordered at the first visit.
- Hold a joint review with the radiology lead, emergency consultant and charge nurse within two weeks, and agree who owns a flagged result while the patient waits for a bed.
Results
Over the following quarter the template change was adopted across both emergency bays and the two outlying clinics. The audit found three further reports filed against the wrong encounter, all of which were corrected within the same shift once identified. Return visits with an abnormal observation that triggered an imaging review rose in the first month, partly because the checklist made the question visible. Ruth's case was reviewed with her consent and she was told the outcome. The department now treats an urgent flag as open until a named clinician has accepted it in the record.
Questions for discussion
- Which parts of Ruth's second visit should have changed the team's assessment of the first visit, and how would you have recorded that change?
- Where in your own department could a result be filed in a way that leaves the flag invisible to the next shift, and who would notice first?
- How should a protocol balance the speed of a phone call with the need for a written, linked record, and which of the two should carry more weight when they disagree?
Case Study 2
The handover sheet that left out one pending comparison
Brightwater Health Partners, a three-site outpatient and inpatient imaging network with a central reporting service.
The situation
Marcus, a senior radiographer, led the day-to-night handover for the interventional list at the central site. Eleven patients were booked for the following morning, and the handover sheet had been built from the scheduling system, a spreadsheet of pending reports and the paper request log kept at reception. Two of the bookings depended on a prior study that had been requested but not yet reported. One of those prior studies was on the spreadsheet. The other was on the paper log only, because it had been requested by a referring clinic that used a fax form. The night team received a sheet that looked complete, and the day team had assumed the paper log had been transcribed.
The challenge
The handover was not careless. The sheet was the product of three sources, each of which was reasonable on its own, and the template had no field for requests that existed outside the system. The team now had to decide whether to hold the two dependent bookings, contact the referring clinic at night, or proceed and rely on the morning review. Each option had a cost, and the people making the decision had only part of the information.
Analysis
The patients on the list needed two things from the handover: confidence that their studies would be ready and reviewed in time, and an accurate picture of which prior results their bookings depended on. The clinical evidence that mattered was the status of the prior studies, not the general state of the worklist. A prior report that is pending is not the same as a prior report that has been requested but never entered. Careful handover practice separates those states explicitly, because a handover that merges them will look complete while hiding the one item that needs a decision before morning.
Applicable protocols here are the handover standard and the referral policy, and they point in different directions. The handover standard asks that every pending item be named, owned and given a next action. The referral policy asks that a clinic-generated request be entered in the system within a set period of receipt. Neither document anticipated a paper form that bypassed both. The team's best safeguard is therefore not a longer sheet but a single reconciliation step, performed by someone other than the person who built the sheet, that compares the schedule against every source of requests before the handover is signed.
Actions taken
- Add a mandatory source line to the handover template that lists every system and paper log checked, so the sheet shows how the list was built and which sources were not searched.
- Introduce a reconciliation step in which a second staff member compares the next day's bookings against the referral log and the paper request log, and signs off any dependent booking before the handover.
- Agree with the two largest referring clinics that requests will be entered electronically within one working day, and retire the fax form for any study that feeds a same-week booking.
- Measure the gap for one quarter by recording how many handovers include a dependent booking with an untraced prior, and set a target for reducing that count before judging the template change.
Results
The on-call route was used for the dependent booking on that night, and the referring clinic confirmed the study had been performed but not entered, so the booking was reviewed in the morning with the report in hand. In the following quarter the reconciliation step caught two further untraced priors before the handover was signed. The gap count fell from four handovers in the first month to one in the last month of the quarter. The team still finds that the fax form is the weak point, and the clinic agreement is being monitored rather than assumed.
Questions for discussion
- Which source on the paper log would have been easiest to miss in your own handover, and what would make it visible without relying on memory?
- When a reconciliation step finds an untraced item late in the evening, who has the authority to hold a booking, and who should be told first?
- How would you judge whether a handover template is working, given that the events it prevents are, by design, the ones that do not happen?
Case Study 3
Choosing which scans wait when the scanner is short
Kestrel Ridge Imaging Network, three hospital sites and two community centers sharing one radiographer rota and two MRI scanners.
The situation
For most of the winter period the network's outpatient MRI list ran at close to full capacity, with a waiting list that had grown to a little over six hundred requests. Two of the four radiographer posts for the evening session were vacant, and one scanner was down for a planned engineering check that had slipped by a week. Requests arrived from three sources: the emergency departments, the inpatient wards, and general practice referrals triaged by a central clerical team. The clinical leads had agreed priority categories on paper, but the categories were applied inconsistently, and the scheduling clerks had been moving bookings by hand to fill gaps.
The challenge
The network manager, Adaeze, had to recover enough capacity to clear urgent requests within the agreed window without pushing the routine list further out than the referral policy allowed. Each option moved risk somewhere else. Extra sessions would draw on radiographers already covering two sites, a sequencing change would delay routine patients who had waited longest, and a sharper triage rule would need agreement from clinicians who had not been consulted on its wording.
Analysis
Patient need in a queue like this is not uniform. A request from an emergency department carries a clinical question that may change management within hours, while a routine referral may have waited months for a result that is only needed to confirm a plan. The evidence the team had was the referral text and the triage category, and both were thin. A category applied inconsistently is worse than a rough category applied consistently, because the clerks and the clinicians were each reading the same words differently. Good practice starts by asking whether the triage question has a single agreed answer before discussing how many sessions to add.
The applicable protocols are the referral policy, which sets the maximum wait for each category, and the local rota agreement, which sets minimum cover for each session. These two documents interact. Adding sessions requires radiographers, and the rota agreement does not allow a radiographer to cover more than one site in a single shift without a supervisor on each. Moving urgent requests forward is permitted, but only if the bumped routine patients are contacted and offered a revised date. The team's options therefore need to be assessed against both documents, and the decision should be recorded with the reason each option was accepted or set aside.
- Triage Apply the agreed category to every request, and log any change to the category with a reason.
- Schedule Fill sessions by category order and hold a reserve slot for urgent requests.
- Allocate Assign radiographer cover and any scanner downtime to sessions before bookings are confirmed.
- Review Compare waits by category against policy limits each week and report breaches.
Actions taken
- Rewrite the triage categories with worked examples drawn from past requests, and have the clinical leads and two clerks each score the same twenty referrals before the wording is adopted.
- Set a fixed reserve of urgent slots in each session, sized from the previous quarter's emergency requests, and release unused reserve to routine patients only at a set time on the day.
- Ask the two sites with spare radiographer time to cover one evening session each week under a written cross-site agreement that names the supervisor on each shift.
- Contact every routine patient moved by a resequencing change within one working day, offer a revised date in writing, and log the reason so the review can see how often this happens.
Results
The triage rewrite reduced disagreement between clerks and clinicians on the sampled referrals, and the reserve slots were used on most sessions without leaving routine patients beyond the policy limit. The cross-site cover ran one evening session in most weeks, though twice it was cancelled when a supervisor was unavailable. The routine list fell more slowly than hoped. Patients who were moved were contacted, and the logged reasons showed that most moves were caused by scanner downtime rather than by the reserve. The weekly review now shows waits by category.
Questions for discussion
- If the clinical leads and the clerks disagree on a triage category, who should settle it, and how quickly does that decision need to happen?
- What would you lose by reserving urgent slots in every session, and how would you know if the reserve was too large?
- When a routine patient is moved to make room for an urgent request, what obligation does the service have that goes beyond the letter of the referral policy?
Case Study 4
Why similar reports gave inconsistent turnaround times
Larkspur Community Radiology, a hospital-affiliated reporting service covering two emergency sites and four outpatient clinics.
The situation
Larkspur Community Radiology had reported a wide spread in turnaround times for similar studies over the previous two quarters. Two radiologists reporting the same type of abdominal study were averaging times that differed by more than a day, and the emergency sites had started to raise the issue in their monthly meetings. The service's indicators were routine: turnaround against target, the proportion of reports with all structured fields completed, and the number of addenda issued after clinician queries. Nothing in the summary explained the gap. The service lead, Priya, asked for an anonymized review of individual reports to see whether the difference came from case mix, reporting practice, or the way work was allocated.
The challenge
The review had to be done without identifying patients or individual reporters in a way that would turn the audit into a performance file. A reviewer could read every report in the sample and still not know whether delay came from the report itself, the queue ahead of it, or the time taken to reconcile the request with the prior images. The findings also had to be shared with the emergency sites in a way that did not suggest blame.
Analysis
The patients behind these indicators were not a single group. Some studies were requested as urgent, and a day's delay changed the decisions the treating team could make. Others were routine follow-up imaging, where a longer turnaround caused little clinical harm but did generate repeat queries and anxiety for the patient. An indicator that averages both kinds of study can look like a process failure when it is really a mix problem. The first analytic step was therefore to stratify the sample by request priority and by the clinical question on the request form, so that the comparison was between like studies. Only then did the averages mean anything.
Two protocols govern this work: the reporting standard, which sets the structured fields that must be complete before sign-off, and the service turnaround policy, which sets targets by priority. A report can satisfy one and fail the other. When the review cross-tabbed the two, a pattern appeared: the reports that skipped structured fields were the ones most often sent back for addenda, and they also sat longest in the verification queue, where second readers reconstructed missing information. The process cause was therefore a sign-off step that allowed incomplete reports to pass, and the timing cause was the rework that followed. Neither could be fixed by asking individual radiologists to work faster.
Actions taken
- Build a two-way extract from the reporting system that pairs each sampled report's structured field completion with its turnaround and addenda count, with patient and reporter identifiers removed.
- Make completion of the structured fields a hard stop at sign-off for the two highest-volume study types, and record the reason whenever the stop is overridden.
- Route reports returned for addenda into a separate queue with a fixed daily reader allocation, so rework does not compete with first reads during the busiest sessions.
- Run the cycle for two quarters with a monthly run chart of turnaround and completion by priority, and agree in advance the change that would count as evidence the process is working.
Results
The first extract showed that reports missing structured fields were overrepresented in the delayed quadrant. After the hard stop was introduced for the two highest-volume study types, the proportion of sign-offs with complete fields rose and the number of addenda in those types fell over the following quarter. Turnaround for urgent requests improved more slowly, because the queue was also short of reader time on some days. The emergency sites received the findings as a process review rather than an individual one, and the monthly meeting now reviews the run chart before raising a concern.
Questions for discussion
- Which of the indicators you currently report would have hidden the process problem described here, and what would you add to expose it?
- How would you explain to a referring team that a turnaround target was missed, when the delay came from rework that the team itself had created?
- What should count as enough evidence that a hard stop is working, and what would be the first sign that it has moved the problem somewhere else?
Case Study 5
A daughter requests results her mother withheld
Gullmarsh Community Imaging Service, a county-funded outpatient imaging provider with two sites and a shared records portal.
The situation
Teresa, a retired bookkeeper in her seventies, attended a community imaging appointment that had been requested by her general practitioner for a symptom review. During the scan the radiographer noted that the reporting radiologist would need to review a finding that might need further assessment. Teresa was given a leaflet, a date for the report, and the name of the clinic that would contact her. Two weeks later her daughter, Karen, who helps manage her appointments and holds proxy access to the patient portal, phoned the department asking for the full report and a summary of what was found. Karen said her mother had been unwell and that she needed to know what to plan for.
The challenge
The record showed that Teresa had asked, at booking, that results go to her and to her general practitioner only. The record also showed that Karen held valid proxy access, and that the portal had released the appointment letter to her account the week before. The team had a duty to Teresa's stated wishes, a duty to act on a possible finding, and a duty to avoid disclosing confidential information to someone without authority. Karen's concern was real, and the phone call was not a request to be dismissed.
Analysis
Teresa's needs are split across two questions. She needs to know that a finding requires follow-up. She also has a recorded decision about who receives her information, and that decision holds unless there is a lawful basis to depart from it. The clinical evidence is a finding that needs assessment, not a diagnosis, so the urgency lies in making sure the follow-up is arranged and that Teresa knows it is needed. A conversation that tells Karen the team cannot share details yet, and invites Teresa to decide, respects both people. Good practice starts from the recorded wishes, then asks directly what the patient wants shared.
The applicable protocols are the confidentiality policy, the proxy access agreement, and the escalation route for findings that need follow-up. The proxy agreement gives Karen access to appointments and letters, but it does not extend to clinical reports unless the patient has said so. The escalation route required the reporting radiologist to send the follow-up recommendation to the referring practitioner, and to name the person responsible for the next step. Escalation in this case meant the radiographer telling the reporting radiologist, the radiologist informing the practitioner, and the information governance lead being asked to confirm how the phone request should be handled. No single person should decide alone.
Actions taken
- Call Teresa, confirm her current wishes about sharing, and offer to speak with Karen with Teresa present or with her written agreement recorded first.
- Tell Karen, in a short call, that the team cannot release clinical details without Teresa's agreement, that the follow-up is being arranged, and when she can expect contact.
- Refer the request to the information governance lead within the same working day, and ask for a written decision on how future calls from proxies should be handled for this patient.
- Confirm with the reporting radiologist that the follow-up recommendation has reached the general practitioner in writing, and record the named clinician responsible for the next step.
Results
Teresa confirmed that she wanted her general practitioner to receive the report and that she would decide later whether Karen should be involved. She attended a conversation with Karen present, and agreed that Karen could hear the follow-up plan but not the full report. The information governance lead issued a written note for the proxy record, which the clerks now check at each call. The follow-up appointment was booked within the agreed window. Karen later said the call had felt like being shut out, and the service accepted that the first reply had sounded more like a refusal than an explanation.
Questions for discussion
- When a patient's recorded wishes and a family member's concern point in different directions, what would you need to see before changing how information is shared?
- How would you phrase the first reply to Karen so that it explains the limit without sounding like a refusal?
- Which of the five weights in the chart would you revise after a week, and what new fact would move it?
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