Diagnostic errors in abdominopelvic CT interpretation: characterization based on report addenda

Abstract

Purpose

The purpose of the article is to characterize the diagnostic errors in abdominopelvic CT interpretation through review of radiology report addenda.

Methods

We searched abdominopelvic CT reports for the word “addendum” over a nearly seven-year period. Addenda were reviewed to identify those reporting a diagnostic error. Cases were characterized by a spectrum of features.

Results

709 addenda describing 785 diagnostic errors were identified, representing approximately 0.5% of searched reports. 84.1% were a new finding, 5.1% an upgrade in severity of an originally reported finding, 3.9% a downgrade in severity, and 6.9% other modification. The most common anatomic sites, as well as the most common missed abnormality per site, were vasculature (9.8%, atherosclerosis/thrombus), abdominal wall (8.3%, ventral hernia), bone [7.4%, osseous lesion (not clearly benign)], kidney [6.9%, renal lesion (not clearly benign)], liver (6.1%, steatosis), and ureter (5.1%, calculus). Of 209 addenda providing a reason for the change, 30.6% related to comparison with prior imaging, 22.5% additional surgical history, 13.4% referrer request for re-review, 8.6% additional signs, symptoms, or lab abnormality, 8.6% additional known diagnosis, 5.7% attention to patient gender, 5.3% multi-planar reconstructions, and 5.3% consultation with other radiologist.

Conclusion

Missed findings rather than misinterpretations of detected abnormalities were the most common reason for abdominopelvic CT report addenda. Awareness of the most common misses by anatomic location may help guide quality assurance initiatives. A wide variety of contributing factors were identified. Informatics and workflow optimization may be warranted to facilitate radiologists’ access to all available patient-related data, as well as communication with other physicians, and thereby help reduce diagnostic errors.