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Approach to Characterising Radiological Errors

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Pitfalls in Diagnostic Radiology

Abstract

Radiology involves decision-making under conditions of uncertainty and, therefore, errors are common. Radiologists should be aware of the most common causes of error in their day-to-day practice and be willing to report and learn from near misses and adverse events in order to minimise the occurrence of preventable errors. Many factors, including interaction between medical, technical and supporting staff both within and outside the radiology department, and the various systems in place determine how likely it is that error may occur. Only by having a system for detecting, classifying and managing mistakes can error be reduced and thus the quality of patient care improved. The huge spectrum of interrelated contributing factors can make classification of errors difficult. The current approaches to classification and reduction of error in radiology departments are discussed.

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Abbreviations

CT:

Computed tomography

PACS:

Picture archiving and communication system

References

  • Ashman CJ, Yu JS, Wolfman D (2000) Satisfaction of search in osteoradiology. AJR Am J Roentgenol 175:541–544

    Article  CAS  PubMed  Google Scholar 

  • Bechtold RE, Chen MYM, Ott DJ et al (1997) Interpretation of abdominal CT: analysis of errors and their causes. J Comput Assist Tomogr 21:681–685

    Article  CAS  PubMed  Google Scholar 

  • Berbaum KS, Franken EA, Dorfmann DD et al (1990) Satisfaction of search in diagnostic radiology. Invest Radiol 25:133–140

    Article  CAS  PubMed  Google Scholar 

  • Berlin L (1977) Does the “missed” radiographic diagnosis constitute malpractice? Radiology 123:523–527

    Article  CAS  PubMed  Google Scholar 

  • Berlin L (1994) Reporting the “missed” radiologic diagnosis: medicolegal and ethical considerations. Radiology 192:183–187

    Article  CAS  PubMed  Google Scholar 

  • Berlin L (1996a) Perceptual errors. AJR Am J Roentgenol 167:587–590

    Article  CAS  PubMed  Google Scholar 

  • Berlin L (1996b) Malpractice issues in radiology: errors in judgement. AJR Am J Roentgenol 166:1259–1261

    Article  CAS  PubMed  Google Scholar 

  • Berlin L, Hendrix RW (1998) Perceptual errors and negligence. AJR 170:863–867

    Google Scholar 

  • Berlin L (2000a) Liability of interpreting too many radiographs. AJR Am J Roentgenol 175:17–22

    Article  CAS  PubMed  Google Scholar 

  • Berlin L (2000b) Malpractice issues in radiology. Alliterative errors. AJR Am J Roentgenol 174:925–931

    Article  CAS  PubMed  Google Scholar 

  • Berlin L (2001) Defending the “missed” radiographic diagnosis. AJR Am J Roentgenol 176:317–322

    Article  CAS  PubMed  Google Scholar 

  • Berlin L (2007) Accuracy of diagnostic procedures: has it improved over the past five decades? AJR Am J Roentgenol 188:1173–1178

    Article  PubMed  Google Scholar 

  • Brook OR, O’Connell AM, Thornton E et al (2010) Quality initiatives: anatomy and pathophysiology of errors occurring in clinical radiology practice. RadioGraphics 30:1401–1410

    Article  PubMed  Google Scholar 

  • Buchanan GN, Halligan S, Taylor S et al (2004) MRI of fistula in ano: inter- and intraobserver agreement and effects of directed education. AJR Am J Roentgenol 183:135–140

    Article  PubMed  Google Scholar 

  • Burnside ES, Sickles EA, Bassett LW et al (2009) The ACR BI-RADS experience: learning from history. J Am Coll Radiol 6:851–860

    Article  PubMed Central  PubMed  Google Scholar 

  • Chan HP, Hadjilski L, Zhou C et al (2008) Computer-aided diagnosis of lung cancer and pulmonary embolism in computed tomography-a review. Acad Radiol 15:535–555

    Article  PubMed Central  PubMed  Google Scholar 

  • Chang A, Schyve PM, Croteai RJ, O’Leary DS, Loeb JM (2005) The JCAHO patient safety event taxonomy: a standardized terminology and classification schema for near misses and adverse events. Int J Qual Health Care 17:95–105

    Article  PubMed  Google Scholar 

  • Chang CA, Strahan R, Jolley D (2011) Non-clinical errors using voice recognition dictation software for radiology reports: a retrospective audit. J Digit Imaging 24:724–728

    Article  PubMed Central  PubMed  Google Scholar 

  • Clinton HR, Obama B (2006) Making patient safety the centerpiece of medical liability reform. N Engl J Med 354:2205–2208

    Article  CAS  PubMed  Google Scholar 

  • Donald JJ, Barnard SA (2012) Common patterns in 558 diagnostic radiology errors. J Med Imaging Radiat Oncol 56:173–178

    Article  PubMed  Google Scholar 

  • Eldevik OP, Dugstad G, Orrison WW et al (1982) The effect of clinical bias on the interpretation of myelography and spinal computed tomography. Radiology 145:85–89

    Article  CAS  PubMed  Google Scholar 

  • Erly WK, Ashdown BC, Lucio RW et al (2003) Evaluation of emergency CT scans of the head: is there a community standard? AJR Am J Roentgenol 180:1727–1730

    Article  PubMed  Google Scholar 

  • Fitzgerald R (2005) Radiological error: analysis, standard setting, targeted instruction and teamworking. Eur Radiol 15:1760–1767

    Article  PubMed  Google Scholar 

  • Garland LH (1949) On the scientific evaluation of diagnostic procedures. Radiology 52:309–328

    Article  CAS  PubMed  Google Scholar 

  • Garland LH (1959) Studies on the accuracy of diagnostic procedures. AJR Am J Roentgenol 82:25–38

    CAS  Google Scholar 

  • Good BC, Cooperstein L, DeMarino GB et al (1990) Does knowledge of the clinical history affect the accuracy of chest radiographic interpretation? AJR Am J Roentgenol 154:709–712

    Article  CAS  PubMed  Google Scholar 

  • Kahn CE, Langlotz CP, Burnside ES et al (2009) Towards best practice in radiology reporting. Radiology 252:852–856

    Article  PubMed  Google Scholar 

  • Krupinski EA, Berbaum KS, Caldwell RT et al (2010) Long radiology workdays reduce detection and accommodation accuracy. J Am Coll Radiol 7:698–704

    Article  PubMed Central  PubMed  Google Scholar 

  • Kundel HL (1989) Perception errors in chest radiography. Semin Resp Med 10:203–210

    Article  Google Scholar 

  • Kundel HL, Nodine CF, Carmody DP (1978) Visual scanning, pattern recognition and decision-making in pulmonary nodule detection. Invest Radiol 13:175–181

    Article  CAS  PubMed  Google Scholar 

  • Kundel HL, Nodine CF, Krupinski EA (1989) Visual dwell indicates locations of false-positive and false-negative decisions. Invest Radiol 24:472–478

    Article  CAS  PubMed  Google Scholar 

  • Mang T, Bogoni L, Salganicoff M et al (2012) Computer-aided detection of colorectal polyps in CT colonography with and without fecal tagging: a stand-alone evaluation. Invest Radiol 47:99–108

    Article  PubMed  Google Scholar 

  • Markus JB, Somers S, Franic SE, Moola C, Stevenson GW (1989) Interobserver variation in the interpretation of abdominal radiographs. Radiology 171:69–71

    Article  CAS  PubMed  Google Scholar 

  • McCreadie G, Oliver TB (2009) Eight CT lessons that we learned the hard way: an analysis of current patterns of radiological error and discrepancy with particular emphasis on CT. Clin Radiol 64:491–499

    Article  CAS  PubMed  Google Scholar 

  • McGurk S, Brauer K, Macfarlane TV, Duncan KA (2008) The effect of voice recognition software on comparative error rates in radiology reports. Br J Radiol 81:767–770

    Article  CAS  PubMed  Google Scholar 

  • Oestmann JW, Greene R, Kushner DC et al (1988) Lung lesions: correlation between viewing time and detection. Radiology 166:451–453

    Article  CAS  PubMed  Google Scholar 

  • Pauli R, Hammond S, Cooke S et al (1996) Radiographers as film readers in screening mammography: an assessment of competence under test and screening conditions. Br J Radiol 69:10–14

    Article  CAS  PubMed  Google Scholar 

  • Potchen EJ (2006) Measuring observer performance in chest radiology: some experiences. J Am Coll Radiol 3:423–432

    Article  PubMed  Google Scholar 

  • Reason J (1990) The contribution of latent human failures to the breakdown of complex systems. Philos Trans R Soc London B Biol Sci 327:475–484

    Article  CAS  PubMed  Google Scholar 

  • Reason J (2000) Human error: models and management. BMJ 320:768–770

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  • Renfrew DL, Franken EA, Berbaum KS, Weigelt FH, Abu-Yousef MM (1992) Error in radiology: classification and lessons in 182 cases presented at a problem case conference. Radiology 183:145–150

    Article  CAS  PubMed  Google Scholar 

  • Robinson PJA (1997) Radiology’s Achilles’ heel: error and variation in the interpretation of the Rontgen image. Br J Radiol 70:1085–1098

    Article  CAS  PubMed  Google Scholar 

  • Smith MJ (1967) Error and variation in diagnostic radiology. CC Thomas, Springfield, pp 33–63

    Google Scholar 

  • Stevenson CA (1969) Accuracy of the X-ray report. JAMA 207:1140–1141

    Article  CAS  PubMed  Google Scholar 

  • Stewart RM, Corneille MG, Johnston J et al (2006) Transparent and open discussion of errors does not increase malpractice risk in trauma patients. Ann Surg 243:645–649

    Article  PubMed Central  PubMed  Google Scholar 

  • Taylor SA, Burling D, Roddie ME et al (2008) Computer-aided detection for CT colonography: incremental benefit of observer training. Br J Radiol 81:180–186

    Article  CAS  PubMed  Google Scholar 

  • The Royal College of Radiologists (2007a) Standards for self-assessment of performance. The Royal College of Radiologists, London

    Google Scholar 

  • The Royal College of Radiologists (2007b) Standards for radiology discrepancy meetings. The Royal College of Radiologists, London

    Google Scholar 

  • The Royal College of Radiologists (2012a) Clinical radiology workload: guidance on radiologists’ reporting figures. The Royal College of Radiologists, London

    Google Scholar 

  • The Royal College of Radiologists (2012b) Standards for the communication of critical, urgent and unexpected significant radiological findings. The Royal College of Radiologists, London

    Google Scholar 

  • Tudor GR, Finlay D, Taub N (1997) An assessment of inter-observer agreement and accuracy when reporting plain radiographs. Clin Radiol 52:235–238

    Article  CAS  PubMed  Google Scholar 

  • von Kummer R (1998) Effect of training in reading CT scans on patient selection for ECASS II. Neurology 51(suppl 3):S50–S52

    Article  Google Scholar 

  • White K, Berbaum K, Smith WL (1994) The role of previous radiographs and reports in the interpretation of current radiographs. Invest Radiol 29:263–265

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Diagnostic Imaging, Imperial College Healthcare NHS Trust, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF, UK

    Mary E. Roddie FRCP, FRCR

Authors
  1. Mary E. Roddie FRCP, FRCR
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Corresponding author

Correspondence to Mary E. Roddie FRCP, FRCR .

Editor information

Editors and Affiliations

  1. Department of Diagnostic Radiology, Khoo Teck Puat Hospital, Alexandra Health, Singapore, Singapore

    Wilfred C. G. Peh

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Roddie, M.E. (2015). Approach to Characterising Radiological Errors. In: Peh, W. (eds) Pitfalls in Diagnostic Radiology. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-662-44169-5_7

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  • DOI: https://doi.org/10.1007/978-3-662-44169-5_7

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  • Publisher Name: Springer, Berlin, Heidelberg

  • Print ISBN: 978-3-662-44168-8

  • Online ISBN: 978-3-662-44169-5

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