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.

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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.”

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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.

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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.

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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.