Search results for "United States of America"

This study analyzed a database of voluntarily reported errors to determine the types of radiologic errors encountered in a regional pediatric emergency medicine network. Radiologic errors accounted for 7% of all incident reports, of which the most common were incorrect or changed interpretations of studies. Individual errors—including clinical judgment or failure to follow established safety procedures—were judged to be more common than system factors, though only half of the incident reports described contributing causes.

This review summarizes key principles of high quality care and how they can be applied to augment radiology practice. Recommended safety improvement strategies included plan-do-study-act cycles, change management, and balanced scorecards.

Interpretive radiology errors can result in delays that contribute to patient harm. This commentary describes human factors that affect diagnostic accuracy and reviews strategies to address weaknesses at the individual and systems level.

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.

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.

Misinterpretation of test results can have harmful consequences for patients. This commentary discusses interpretive and perceptual errors in radiology and explores why these failures occur. The authors recommend strategies to reduce errors in radiology, including cognitive debiasing and use of checklists.

Collective intelligence encompasses several methods for summarizing input from multiple individuals, which can often be more accurate than any one expert. In this study, investigators applied several collective intelligence algorithms to mammography interpretation. They found that aggregating the interpretations of multiple radiologists resulted in higher accuracy—fewer false positive results and more true positive results—than even the most accurate single radiologist. This work builds on earlier studies of diagnostic accuracy in imaging studies. This study has profound implications for improving diagnosis through collaboration between clinicians in real time, perhaps facilitated through technology, as a complement to the long-standing diagnostic safety strategy of morbidity and mortality conferences, which provide group feedback once a case has concluded.

Despite The Joint Commission requirement to use at least two patient identifiers when obtaining an imaging study, wrong-patient events still occur. This retrospective case review study determined the prevalence of reported near-miss wrong-patient events in radiology at two large academic hospitals. The overall event rate was 4 per 100,000 radiology studies.

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.

Interruptions are inevitable for busy clinicians, and recently studies have shown that interruptions can increase workload for physicians and raise the risk of medication administration errors by nurses. However, these safety risks must be balanced against the fact that interruptions are often necessary for patient care. This study analyzed data from telephone logs and a formal quality assurance program to examine the effect of telephone interruptions on accuracy of on-call radiology residents' study interpretations. The authors found that a higher frequency of interruptions was associated with more diagnostic errors. This study is one of the first to document clinical consequences of physician interruptions and adds to our understanding of systems contributors to diagnostic errors. An incident involving an incorrect overnight radiology interpretation is discussed in a past AHRQ WebM&M commentary.

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.

This study found that diagnostic errors in interpretation of pediatric musculoskeletal radiographs were relatively rare, occurring in 2.7% of cases. The majority of errors involved false negative readings (i.e., missed injuries).

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).

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.

Recognizing and weighing harms associated with treatment is a core aspect of patient safety. Recently, low-dose computed tomography (LDCT) screening for lung cancer has been promoted by the 20% relative reduction in lung cancer-specific mortality found in a large clinical trial. This study evaluated National Lung Cancer Screening Trial data to determine an estimate of LDCT-detected lung cancer that would not otherwise become clinically apparent—or cancer overdiagnosis. Using these calculations, approximately 20% of cancers detected by LDCT screening represented overdiagnosis. From a research perspective, this study advances our understanding of the measurement of overdiagnosis, and this approach may also be useful for evaluating overdiagnosis of other conditions. A recent AHRQ WebM&M interview with Dr. Rebecca Smith-Bindman discussed radiation safety and the implications of increasing use of CT scans.

This review examines diagnostic errors and cognitive biases in radiology practice and includes strategies to address them.

Written as a poem, this piece reviews concerns influencing radiologists' error disclosure and highlights how open communication can benefit both patients and physicians.

Automatically photographing patients at the time of portable chest radiography increased the detection of mislabeled radiograph errors without significantly affecting film interpretation time.

This radio interview discusses how inattentional blindness can occur in radiology and describes a test that exposes such risks.

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.