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RADIOLOGIC ERRORS:CAUSES AND CURES
Society for Emergency Radiology,Third Annual Meeting
Bengaluru, India September 23-25, 2016
Leonard Berlin, MD, FACRDepartment of Radiology
Skokie Hospital, Skokie, IL
Professor of RadiologyRush University Medical College
andUniversity of Illinois
Chicago, IL
Defining Medical Errors“We are failing to properly distinguish between an
error and a complication….Hospital-acquired infection and pulmonary embolism are not
necessarily medical errors….Many complications are unavoidable patient-related
comorbidities….There is a difference between error, bad results, and unintended
consequences.”Medscape, 5-26-16
Medical Malpractice Lawsuits in the USA
BEFORE 1950: Errors of COMMISSION(The doctor did something wrong)
AFTER 1950: Errors of OMISSION(The doctor failed to do something right)
Amer Med News, 3-20-06
X-ray AccuracyError Rate
Chest 30% Garland 59
Chest 25% Tuddenham 62
Chest 30% Yerushalmy 69
Colon 32% Cooley 60
Bone 30% U of Mo. 76
GI 30% U of Mo. 76
Misc 41% Herman 75
Misc 25-32% Renfrew 92
Percent Of Lung Cancers Found On Retrospective Review Of Chest
X-raysUniversity of Southern California
1960 48%
Harvard 1975 70%
University of California, San Diego
1981 40%
Mayo Clinic 1983 90%
Sloan Kettering 1984 65%
Columbia Presbyterian 1992 73%
Percent of Breast Cancers FoundOn Retrospective Review of
Mammograms
University of Arizona 1993 75%
Yale University 1994 63%
X-ray AccuracyError Rate, More Recent
Lung nodules 30% Sarnel 99 Lung CA CT 53% White 96 Renal CA CT 25% Siegel 99 Misc CA CT 37% Gullub 99 Pulm Angio Embol 36% Van Beek 96 Mammogram 67% Burhenne 2000 Sonography 23% Hertzberg 99 MRI 39% Wakeley 95
Rates of Error in Imaging Interpretation in a Group of
Hospitals
Review of over 11,000 images read by 35 radiologists
4.4% mean rate of interpretation error
Siegle et al. TX Med Cntr, Acad Radiol 1998;5:148
Error Rate Among Radiology Residents: CT and MRI of Head,
Neck and Spine
• 5 year study, Univ. of FL• 21,796 cases• Read by resident, checked by staff rad• Overall error rate 3.9%
Sistrom, Acad Rad 2008;15:934
Retrospective (Research) Error Rate: 30% Range
*************************************************
Everyday “Real-time” Error Rate:3-4%
*******************************************A Distinction
Simple vs Clinically Significant Errors
• A major distinction between simple errors and clinically significant errors must be made.
Radiographic Errors
Perceptual: 70% Cognitive: 30%
(misinterpretation)
19Initial
20Next day
21Initial Scout Image
Alliterative Errors• Occur because radiologists read reports
of previous exams and are more apt to adopt same opinions
• Attributed to tendency and need to conform to their peers or their own previous conclusions
Negligence
A breach of the standard of care
Standard of Care (International)
To conduct oneself as would a reasonably prudent physician under the same or
similar circumstances, i.e., not necessarily ideal, perfect, extraordinary,
excellent.
Standard of Care (International)Continued
The Question is not: “Has the radiologist missed an X-ray finding or made an erroneous
interpretation?
The Question is: “Has the radiologist missed an X-ray finding or made an erroneous interpretation
which could have been missed or made by an ordinary radiologist, practicing in a reasonable
manner?
Hindsight Bias
The tendency for people with knowledge of the actual outcome of any event to believe falsely that they would have predicted the outcome.
Outcome Bias
The tendency for people to attribute blame more readily when the outcome of an event is serious
than when the outcome is comparatively minor
Errare humanum est, perseverare autem diabolicum.
To err is human, but to persist in error is diabolical.
Anonymous
In the 66 years since radiologic errors werefirst acknowledged, the error rates have not
decreased appreciably. This must not dissuade us from making every effort to
reduce them now. Yes, to do so is a daunting challenged but it is one from which we cannot
simply shrug our shoulder and walk away.
Reducing Errors• Possess sufficient knowledge of modality of image • Take a second look when possible• Seek additional patient history and discuss with
referring physician when possible• Ensure prompt transmission of imaging reports to
ordering physician (and to the patient?)• Expend sufficient time for interpreting and reporting• Be cautious about voice recognition, templates, and
proofreading to the extent possible
Beware:
Errors when interpreting plain radiographs occur more often
than when interpreting CT, MRI
3/11/2010 5:48PM
Should You Worry About Radiation from CT Scans?
• Risk of cancer from CT scans are unproved and overemphasized.
• The risk of dying from cancer that is not detected is thousands of times greater than from radiation.
Boodman, Washington Post, 1-5-16
36
LAWYERS vs. DOCTORS
WE CANNOT AVOIDACRIMONY,
EVEN WHEN WE TRY...
Two attorneys boarded an airline flight. One sat in the
window seat, the other sat in the middle seat.
RSNA Malpractice 4
RSNA Malpractice 8
Just before takeoff, a radiologist got on and took
the aisle seat next to the two attorneys.
The radiologist kicked off his shoes wiggled his toes and
was settling in.
Just then, the attorney in the window seat said, “I think I’ll get up and get a
coke.” “No problem,” said the radiologist “I’ll get it
for you.”
RSNA Malpractice 5
While the radiologist was gone, one of the attorneys
picked up one of the radiologist’s shoe and spat
in it.
When the radiologist returned with the coke the other attorney said, “that
looks good, I think I’ll have one too.” Again, the
radiologist obligingly went to fetch the coke.
RSNA Malpractice 5
While the radiologist was gone, the other attorney
picked up the other shoe...
…and spat in it, in even a larger quantity.
The radiologist returned and they all sat back and enjoyed
the flight.
RSNA Malpractice 5
As the plane was landing, the radiologist slipped his feet into the shoes and knew immediately what had
happened.
“How long must this go on? asked the radiologist . This fighting between our professions? This hatred?
This animosity….
This spitting in shoes and pissing in cokes?
Manneken Pis is a landmark small bronze sculpture in Brussels, depicting a naked little boy urinating into a fountain’s basin. It was designed by Hieronymus Duquesnoy the Elder and put in place almost 400 years ago - in 1618 or 1619.