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Cases & Commentaries
- 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 > Study
Assessing information sources to elucidate diagnostic process errors in radiologic imaging—a human factors framework.
Cochon L, Lacson R, Wang A, et al. J Am Med Inform Assoc. 2018;25:1507-1515.
As the diagnostic safety field has matured, researchers are striving to better define the diagnostic process and identify failure modes that may lead to patient harm. This study utilized human factors engineering approaches to characterize the information sources used in radiologic diagnostic imaging according to the Systems Engineering Initiative for Patient Safety (SEIPS) framework. Most potential errors were related to person-related factors, such as inadequate communication between clinicians, rather than technological factors.