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Search results for "Active Errors"
- Active Errors
- Radiograph Interpretation Error
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Cases & Commentaries
The Missing Abscess: Radiology Reads in the Digital Era
- Spotlight Case
- CME/CEU
- Web M&M
Eliot L. Siegel, MD; January 2017
Following a hysterectomy, a woman was discharged but then readmitted for pelvic pain. The radiologist reported a large pelvic abscess on the repeat CT scan, and the gynecologist took the patient to the operating room for treatment based on the report alone, without viewing the images herself. In the OR, the gynecologist could not locate the abscess and stopped the surgery to look at the CT images. She realized that what the radiologist had read as an abscess was the patient's normal ovary.
Journal Article > Study
Strategies for improving the value of the radiology report: a retrospective analysis of errors in formally over-read studies.
Kabadi SJ, Krishnaraj A. J Am Coll Radiol. 2017;14:459-466.
This retrospective review of imaging studies submitted to a second institution for a second interpretation (over-read) revealed that more than 10% had clinically significant changes between the original interpretation and the second interpretation. Nearly one-quarter of the changes were classified as emergent, requiring immediate notification to a treating clinician. These results demonstrate how imaging interpretation can affect timely and accurate diagnosis.
Journal Article > Commentary
Pediatric chest radiographs: common and less common errors.
Menashe SJ, Iyer RS, Parisi MT, Otto RK, Stanescu AL. AJR Am J Roentgenol. 2016 Aug 4; [Epub ahead of print].
This commentary reviews nine cases involving interpretation errors associated with chest radiographs of children to illustrate common mistakes that can occur in pediatric imaging. Each case concludes with a clinical teaching point for practice improvement.
Cases & Commentaries
The Fluidity of Diagnostic "Wet Reads"
- Web M&M
Cindy S. Lee, MD, and Christopher P. Hess, MD, PhD; May 2016
An older man with a history of heavy smoking and chest pain underwent a chest CT in the emergency department that showed no evidence of an aortic dissection on the preliminary read. Although the patient followed up soon thereafter with a new primary care physician, it was not discovered until several months later that a suspicious lung nodule had been spotted on the initial CT.
Journal Article > Study
Radiologist-initiated double reading of abdominal CT: retrospective analysis of the clinical importance of changes to radiology reports.
Lauritzen PM, Andersen JG, Stokke MV, et al. BMJ Qual Saf. 2016;25:595-603.
Repeat interpretation of radiological images is known to yield more accurate diagnosis. Investigators interpreted more than 1000 abdominal CT scans twice and found clinically significant changes on the second read in 14% of cases. The authors suggest that using expert second radiology interpretation may enhance diagnostic accuracy.
Journal Article > Study
Improvement in detection of wrong-patient errors when radiologists include patient photographs in their interpretation of portable chest radiographs.
Tridandapani S, Olsen K, Bhatti P. J Digit Imaging. 2015;28:664-670.
This innovative pilot study found significant improvement in radiologists' ability to detect wrong-patient errors when patient photographs were provided with radiographs. The authors advocate for including photographs with portable radiographs to prevent patient mislabeling errors and augment safety.
Special or Theme Issue
Pearls, Pitfalls, and Errors in Musculoskeletal Diagnosis.
Blankenbaker DG, ed. AJR Am J Roentgenol. 2014;203:476-593.
Articles in this special issue discuss common pitfalls in musculoskeletal imaging that can contribute to errors in trauma and extremity injury assessments, magnetic resonance imaging interpretation, and problems with ultrasound use.
Journal Article > Study
Emergency department image interpretation accuracy: the influence of immediate reporting by radiology.
Snaith B, Hardy M. Int Emerg Nurs. 2014;22:63-68.
Immediate reporting of results by radiologists in the emergency department (ED) was associated with a lower incidence of radiology interpretation errors (compared with interpretation by ED staff).
Journal Article > Study
Fool me twice: delayed diagnoses in radiology with emphasis on perpetuated errors.
Kim YW, Mansfield LT. AJR Am J Roentgenol. 2014;202:465-470.
This chart review study found that delayed diagnoses due to error in radiologic interpretation were often perpetuated across multiple examinations and were attributable to well-recognized cognitive error types. These included errors of complacency, insufficient knowledge, and poor communication.
Journal Article > Review
Cognitive and system factors contributing to diagnostic errors in radiology.
Lee CS, Nagy PG, Weaver SJ, Newman-Toker DE. AJR Am J Roentgenol. 2013;201:611-617.
This review examines diagnostic errors and cognitive biases in radiology practice and includes strategies to address them.
Cases & Commentaries
A Picture Speaks 1000 Words
- Web M&M
Robin R. Hemphill, MD, MPH; September 2013
Admitted to the hospital after hours, a patient with a history of type A aortic dissection had his CT scan read as "no acute changes." However, the CT scan had been compared to a text report of a previous scan, rather than the images. The patient died several hours later, and autopsy revealed the dissection had progressed and ruptured.
Journal Article > Commentary
To disclose or not to disclose radiologic errors: should "patient-first" supersede radiologist self-interest?
Berlin L. Radiology. 2013;268:4-7.
Written as a poem, this piece reviews concerns influencing radiologists' error disclosure and highlights how open communication can benefit both patients and physicians.
Audiovisual
Why even radiologists can miss a gorilla hiding in plain sight.
Spiegel A. Morning Edition. National Public Radio. February 11, 2013.
This radio interview discusses how inattentional blindness can occur in radiology and describes a test that exposes such risks.
Journal Article > Study
Diagnostic errors with inserted tubes, lines and catheters in children.
Fuentealba I, Taylor GA. Pediatr Radiol. 2012;42:1305-1315.
Imaging studies are often necessary to determine whether indwelling devices—such as vascular catheters or drainage tubes—have been correctly positioned. This study characterizes the frequency of diagnostic errors among radiologists in analyzing placement of indwelling devices in children.
Journal Article > Study
The effect of clinical history on accuracy of electrocardiograph interpretation among doctors working in emergency departments.
Cruz MF, Edwards J, Dinh DM, Barnes EH. Med J Aust. 2012;197:161-165.
This observational study highlights the framing effect of a suggestive clinical history, which significantly influenced electrocardiograph interpretation by emergency department physicians.
Journal Article > Commentary
The concept of error and malpractice in radiology.
Pinto A, Brunese L, Pinto F, Reali R, Daniele S, Romano L. Semin Ultrasound CT MR. 2012;33:275-279.
This commentary discusses common errors in radiology and describes the differences between adverse outcomes and malpractice.
Journal Article > Study
Common patterns in 558 diagnostic radiology errors.
Donald JJ, Barnard SA. J Med Imaging Radiat Oncol. 2012;56:173-178.
Analysis of radiological diagnostic errors identified over an 8-year period at a New Zealand hospital found that most errors were perceptual in nature—that is, radiologists failed to identify the abnormality—and a smaller proportion were due to incorrect interpretation of findings.
Journal Article > Study
Clinically missed cancer: how effectively can radiologists use computer-aided detection?
Nishikawa RM, Schmidt RA, Linver MN, Edwards AV, Papaioannou J, Stull MA. AJR Am J Roentgenol. 2012;198:708-716.
A computerized clinical decision support system helped radiologists reduce diagnostic errors in mammogram interpretation. However, radiologists ignored more than two-thirds of the prompts provided by the system.
Newspaper/Magazine Article
The hidden dangers of outsourcing radiology.
Eban K. Self Magazine. November 2011.
This magazine article reports on cases in which outsourcing the interpretation of radiology tests contributed to patient harm.
Cases & Commentaries
The Dropped "No"
- Web M&M
Annette J. Johnson, MD, MS; October 2011
When a hospitalized man developed an arrhythmia, the night float resident checked a radiology report that stated the patient had a DVT. Intervention was started based on that assumption. However, the radiology report had been transcribed incorrectly.