Skip to main content

All Content

Search Tips
Save
Selection
Format
Download
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Additional Filters
1 - 20 of 288

A 31-year-old woman presented to the ED with worsening shortness of breath and was unexpectedly found to have a moderate-sized left pneumothorax, which was treated via a thoracostomy tube. After additional work-up and computed tomography (CT) imaging, she was told that she had some blebs and mild emphysema, but was discharged without any specific follow-up instructions except to see her primary care physician.

Miller-Kleinhenz JM, Collin LJ, Seidel R, et al. J Am Coll Radiol. 2021;Epub Jul 16.
Delayed diagnosis and treatment of breast cancer can lead to poor outcomes. Based on multi-year data from one health system, the authors of this cohort study found that black women with screen-detected breast cancers were more likely than white women to experience diagnostic delays, including delays in diagnostic evaluation and biopsy. The delay in diagnosis was also associated with an increase in breast cancer mortality.
Alexander RG, Yazdanie F, Waite S, et al. Front Neurosci. 2021;15:629469.
Incorrect interpretation of radiologic images can result in delayed diagnosis or unneeded additional tests and treatment. This commentary describes the visual illusions radiologists use in detecting and categorizing abnormalities, and recommends further research into the ways visual illusions are used in order to improve diagnostic safety.
Bulliard J‐L, Beau A‐B, Njor S, et al. Int J Cancer. 2021;149(4):846-853.
Overdiagnosis of breast cancer and the resulting overtreatment can cause physical, emotional, and financial harm to patients. Analysis of observational data and modelling indicates overdiagnosis accounts for less than 10% of invasive breast cancer in patients aged 50-69. Understanding rates of overdiagnosis can assist in ascertaining the net benefit of breast cancer screening.
Sajid IM, Parkunan A, Frost K. BMJ Open Quality. 2021;10(3):e001287.
Inappropriate use or overuse of clinical tests such as MRIs can be harmful to patients. This cohort study, including 107 general practitioners across 29 practices, found that only 4.9% of musculoskeletal MRIs were clearly indicated and only 16.7% of results appeared to be correctly interpreted by clinicians, suggesting the potential for significant misdiagnosis and overdiagnosis.

London, UK: Parliamentary and Health Service Ombudsman; 2021. ISBN 9781528627016. 

Lack of appropriate follow up of diagnostic imaging can result in care delays, patient harm, and death. This report summarizes an investigation of 25 imaging failures in the British National Health Service (NHS). The analysis identified communication and coordination issues resulting in lack of action and reporting of unanticipated findings to properly advance care. Recommendations to improve imaging in the NHS include use of previous analyses to enhance learning from failure.
Sivarajah R, Dinh ML, Chetlen A. J Breast Imaging. 2021;3(2):221-230.
This article describes the Yorkshire contributory factors framework, which identifies factors contributing to safety errors across four hierarchical levels (active errors, situational factors, local working conditions, and latent factors) and two cross-cutting factors (communication systems and safety culture). The authors apply this framework to a case of missed mass on breast imaging and discuss how its use can help health systems effectively learn from error and develop systematic, proactive programs to improve safety and manage safety issues.
Walters GK. J Patient Saf. 2021;17(4):e264-e267.
The majority of preventable adverse events are multifactorial in nature and are a result of system failures. Using a case study, the authors outline a series of errors following misplacement of a PICC line. Failures include differences in recording electronic health record notes and communication between providers. Investigations of all adverse events will help identify and correct system failures to improve patient safety.
DeGrave AJ, Janizek JD, Lee S-I. Nature Machine Intel. 2021;Epub May 31.
Artificial intelligence (AI) systems can support diagnostic decision-making. This study evaluates diagnostic “shortcuts” learned by AI systems in detecting COVID-19 in chest radiographs. Results reveal a need for better training data, improved choice in the prediction task, and external validation of the AI system prior to dissemination and implementations in different hospitals.  

Northwest Safety and Quality Partnership. June 22, 2021. 

Diagnostic radiology mistakes contribute to delays and ineffective treatments that contribute to patient harm. This webinar examined factors that contribute to errors in image interpretation and will highlight strategies to learn from those errors to improve diagnostic process reliability. Registering for the program provides access to the recording.

Silver Spring, MD: US Department of Health and Human Services, Food and Drug Administration, Center for Devices and Radiological Health. May 20, 2021.

Magnetic resonance imaging (MRI) suites harbor unique hazards that can harm patients, should process missteps occur. This report shares assessment steps to assure that medical devices are labeled appropriately to support their safe use in the MRI environment and encourages organizational reporting of problems encountered when testing device use.

Harolds JA, Harolds LB. Clin Nucl Med. 2015–2021.

This monthly commentary explores a wide range of subjects associated with patient safety, such as infection prevention, surgical quality improvement, and high reliability organizations.
Kobo-Greenhut A, Sharlin O, Adler Y, et al. Int J Qual Health Care. 2021;33(1):mzaa151.
Failure mode and effect analysis (FMEA) is used to asses risk in various heath care processes. This study found that an algorithmic prediction of failure modes in healthcare (APFMH) is more effective in identifying hazards and uses fewer resources (time and human resource investment) than traditional FMEA.

After a breast mass was identified by a physician assistant during a routine visit, a 60-year-old woman received a diagnostic mammogram and ultrasound. The radiology assessment was challenging due to dense breast tissue and ultimately interpreted as “probably benign” findings. When the patient returned for follow-up 5 months later, the mass had increased in size and she was referred for a biopsy.

FDA Safety Communication. MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; December 7, 2020.

Magnetic resonance imaging (MRI) requires patient preparation steps to protect against inadvertent harm. This announcement cautions patients and providers to assess masks being worn to protect against COVID-19 transmission for metal components that can result in patient burns during the exam. Recommendations for safety include enhanced screening to ensure masks are safe for the exam environment.
Wright B, Lennox A, Graber ML, et al. BMC Health Serv Res. 2020;20(1):897.
Incomplete or delayed test result communication can contribute to diagnostic errors, delayed treatments and patient harm. The authors synthesized systematic and narrative reviews from multiple perspectives discussing diagnostic test result communication failures. The review identified several avenues for improving closed-loop communication through the use of technology, audit and feedback, and use of point-of-care or bedside testing.
Elliott J, Williamson K. Radiography. 2020;26(3):248-253.
Extended work shifts for nurses and physicians have been linked to increased risk of errors. In this systematic review, the authors discuss the impact of shift work disorder on errors and safety implications for radiologists. Studies suggested a positive correlation between errors and increased mental and physical fatigue resulting from shift work or rapid shift rotation, however none of the identified studies focused on radiology professionals.