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Increase Your Awareness and Understanding of Radiologic Error
Increase Your Awareness and Understanding of Radiologic Error
15 strategies to help minimize radiological errors in MRI, CT, and ultrasound imaging.
By Paola A. Baron Ródiz, M.D., Radiology Resident at hospital Universitario Severo Ochoa, Leganes,
Madrid – Spain and Ferreiro Argüelles, M.D., Neuroradiologist at Hospital Universitario Severo
Ochoa in Leganés, Madrid – Spain.
Editor’s Note: The authors of this article received a certificate of merit at ECR 2017 in Vienna for
their research.
Around 250,000 people die each year in the US because of medical errors, according to a study
by researchers at John Hopkins University School of Medicine. This number is bigger than those
who die from car accidents, breast cancers, or work accidents. In fact, medical error constitutes
the third leading cause of death in the United States.exclamation point depicting an error
Radiologist Leo Henry Garland (1903 – 1966) was the pioneer in the study of radiologic error. The
prevalence of radiologists’ errors does not appear to have changed since it was first estimated in
1960. Today, it remains around 10 to 15 percent [1]. Although some diagnoses are missed
because of the limitations of the imaging modality, most of them are attributable to image
interpretation.
Some radiological investigations say that the use of the term “error” is often unsuitable. They
state that it is more appropriate to use the word “discrepancies” between a report and a
retrospective review of a study. Because of the subjectivity of image interpretation, the definition
of error depends on an expert opinion. In that order, an observer makes an error if he or she fails
to reach the same conclusion that would be reached by a group of experts; and errors can only
arise in the cases where the correct interpretation is not in dispute.
A review made in 2001 reported that the prevalence of clinically significant errors in radiology was
in the range of 2 to 20 percent [2]. Approximately 1 billion radiologic imaging examinations are
performed worldwide annually and most of the resulting images are interpreted by radiologists. If
these interpretations carried an average error rate of only 4% (the lowest estimate for the rate of
radiologic error) this would be approximately 40 million radiologist errors per year [1].
MRI, CT and ultrasound radiologic errors can be classified in four broad categories, with
perceptual errors being the more common of them with a 60 – 80% miss rate[1, 5, 6]:
Technique or image acquisition errors: missed because of the technical or physical limitations of
the imaging modality. Contributors to these types of errors include staff shortages, inexperience
of the staff and inadequate equipment.
Artifacts: imaging artifacts or technical factors might obscure the pathology due to image
distortion (false negative) or might mimic pathology (false positive).
Inappropriate study: when the indication of an image test is not correct, and the capability of a
particular radiologic technique might not be suitable for the question that is being asked.
Incomplete study: when the indication of an image test is correct, but does not include all the
areas that must be studied.image of an x and checkmark depicting right and wrong
Under-reading: when the finding is not detected. It is the most common type of error.
Satisfaction of search: when a finding is missed because of failure to complete a systematic search
after discovering an abnormality. It is the second most common type of error.
Satisfaction of report: when a finding is missed because of over reliance on the radiology report
from a previous examination.
Cognitive / interpretative errors: when an abnormality or a normal variant is seen but its meaning
or importance is not correctly understood, resulting in an incorrect diagnosis.
Complacency / Normal variant: when a clinically unimportant finding was appreciated but
attributed to the wrong cause (false positive).
Faulty reasoning: when the finding was appreciated and interpreted as abnormal, but attributed to
the wrong cause (a true positive misclassified).
Lack of knowledge: when the finding is correctly identified on the image, but its diagnostic
importance is missed because of the reader’s lack of knowledge.
Prior examination: when a finding is missed because of failure to consult prior studies or reports.
Communication errors: when the radiologist fails to effectively communicate the results including
errors in the report, in making recommendations and in communicating important findings.
A review of 182 cases made by Blake A. Johnson in 2016 revealed that the most common reasons
for diagnostic errors were: failure to consult prior studies or reports; limitations in imaging
technique (inappropriate or incomplete protocols); inaccurate or incomplete history; location of
the lesion outside of the region of interest; failure to search systematically beyond the first
abnormality discovered; and failure to recognize a normal variant [5].
As we all know, radiologic interpretation is not a binary process. It is a very complex process that
takes far more time than the process of acquiring the images. It is also subject to a wide variety
of factors such as work environment, volume of imaging studies, pressure for fast results, limited
patient information, limited access to clinicians, and distractions inherent to our workplace.
However, as complex as it may be, radiologic interpretation constitutes an important component
of the information available to clinicians to formulate the diagnosis, staging, treatment, and follow
up of their patients.
Therefore, to try to minimize the rate of radiological error, we propose the following general
strategies:
Recognize and correct imaging artifacts by having a basic knowledge of CT and MR physics.
Use appropriate and variable grayscale settings when evaluating CT studies so images have an
appropriate contrast resolution to optimize the visualization of pathologic findings.
Optimize working environment with respect to ergonomics. Avoid interruptions, distractions, and
glare affecting the monitor. Human factors such as excessive workload and fatigue should be
avoided to maintain constant vigilance in interpretation of studies.
Consult the literature when formulating conclusions about an unknown case to formulate a
sufficiently broad range of differential diagnoses and create a program of continuous learning to
prevent knowledge gaps.
Attempt to overcome cognitive biases. Be familiar with causes of diagnostic pitfalls such as
anatomic blind spots or normal anatomic variants to reduce a common cause of misinterpretation.
Consult liberally with colleagues and/or referring physicians when a challenging case is
encountered. Information obtained from these conversations often influences the final report and
helps to avoid interpretative errors.
Create multidisciplinary committees, particularly for cancer care. An important element here is the
double reading of images that is made within the appropriate clinical scenario.
Adopt communication protocols. Many errors are due to a poor communication at some stage in
the imaging / reporting process. The adoption of a protocol for communication of urgent or
unexpected radiological findings may reduce this type of error.
Train radiologists to improve the clarity and effectiveness of their written reports so their message
is not lost or misunderstood.
Try to make double readings to safeguard the quality of the service. However, this strategy implies
a significant manpower issue for its routine adoption. Another option is to establish a peer-review
program in which a percentage of studies are evaluated by colleagues to provide feedback about
any diagnostic errors.
Pay attention to individual physician factors such as illness or advancing age to ensure they do
not significantly affect diagnostic performance.
Use computer-assisted detection if it is possible. Several such systems are available, and although
their clinical effectiveness remains controversial, this area holds much promise.
In summary, we believe that increased awareness of the facts commented above will direct the
actions to help detect and reduce the rate of error. #radiology