Medico‑Legal Expert Urges System‑Level Solutions for Incidental Findings in Emergency Departments

August 26, 2025 at 09:01 AM EDT

GREENSBORO, NC—Jeffrey Segal, MD, JD, founder and CEO of Medical Justice, is sounding the alarm on how U.S. hospitals handle actionable incidental findings (AIFs) discovered during emergency department (ED) imaging. His blog post, titled “Management of Radiographic ‘Incidentalomas’ Discovered in the Emergency Department,” analyzes 2023 best‑practice recommendations from the Journal of the American College of Radiology (JACR). Dr. Segal argues that sustainable, system‑driven protocols—not piecemeal efforts by individual clinicians—are essential to protect patients and mitigate medico‑legal risk.

Each year, more than 100 million Americans visit an ED, and imaging is performed in over half of those encounters; roughly one in five patients receives a CT scan. Research shows that a surprise mass or lesion requiring follow‑up—an AIF—emerges in up to 30 percent of all imaging studies and in nearly one‑third of ED CT exams, an alarmingly significant number.

“These numbers translate into millions of patients who leave the hospital unaware that a potentially life‑altering abnormality has been discovered,” Dr. Segal said. “When communication breaks down, missed follow‑up can delay the diagnosis of early cancers, increase morbidity and mortality, and expose hospitals and physicians to significant liability.”

The ED, he noted, is uniquely ill‑suited for delivering this information. Physicians are focused on stabilizing life‑threatening conditions; many patients lack a primary‑care physician, and responsibility for follow‑up becomes murky when care is handed off to hospitalists or community providers.

“Expecting a lone radiologist or emergency clinician to shepherd each incidentaloma through the healthcare maze is unrealistic,” Dr. Segal continued. “We need a closed‑loop process that does not rely on heroic individual effort.”

The JACR panel, composed of radiologists, emergency physicians, health‑system leaders, and patients, reached strong consensus on four pillars of AIF management: structured reporting, patient communication, clinician communication, and electronic tracking. Key recommendations include templated radiology reports that clearly flag an AIF, specify lesion size and recommended follow‑up, and use patient‑facing language; verbal disclosure of the finding to the patient before ED discharge, reinforced by written instructions; and automated registries that trigger reminders until appropriate imaging or specialist consultation is documented.

Dr. Segal applauds the template‑driven approach. “A structured report is the foundational data point that feeds everything downstream, from electronic alerts to patient notifications,” he explained. “If you can’t reliably extract the finding from the medical record, you can’t build a safety net around it.”

Still, the panel acknowledged weaker agreement on who should notify primary‑care physicians or admitting teams, reflecting the real‑world complexity of hand‑offs. Dr. Segal views that ambiguity as a compelling argument for hospital investment in centralized tracking of incidentalomas.

“Whether the alert is generated by natural‑language processing or a manual flag, best practice is to assign a dedicated navigator, someone whose sole job is to chase the loop until it’s closed,” he said. “Yes, it costs money up front, but missed cancers are far more expensive, both clinically and legally.”

Technological advances can streamline the task. “Artificial intelligence is poised to do the heavy lifting, auto‑identifying suspicious phrases, scheduling follow‑up imaging, even texting reminders to patients,” Dr. Segal observed. “But AI is only as good as the workflow you plug it into. Without governance, algorithms just amplify chaos.”

He also cautioned against over‑diagnosis anxiety. “Not every incidental nodule is malignant,” he said. “Patients deserve balanced counseling about false positives and the risks of further testing. Yet the medico‑legal peril lies at the opposite extreme—when a true malignancy is missed because no one owned the follow‑up.”

For now, Dr. Segal urges hospital leaders to treat the JACR paper as a blueprint, not a luxury. “Best practices are not synonymous with the legal standard of care—until they are,” he warned. “Courts look to published consensus as one factor when adjudicating negligence. Health systems that procrastinate on AIF tracking run the risk of being judged by guidelines they ignored.”

Medical Justice, which provides medico‑legal support, protection plans for doctors, and reputation management for physicians with eMerit nationwide, will continue to monitor how health systems implement these recommendations.

“Our mission is to ensure doctors can focus on patient care while staying on solid legal ground,” Dr. Segal said. “Actionable incidental findings represent a perfect storm of clinical uncertainty and legal exposure. With the right systems, we can turn that storm into a safety net.”

Healthcare professionals seeking guidance on medico‑legal risk management or who are interested in protection plans and online reputation management can schedule a complimentary 15‑minute consultation with the Medical Justice team online.

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For more information about Medical Justice, contact the company here:

Medical Justice
Robin Mahaffey
1-877-633-5878
rmahaffey@medicaljustice.com

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Medico‑Legal Expert Urges System‑Level Solutions for Incidental Findings in Emergency Departments

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