Imaging Pearls ❯ Practice Management ❯ Errors in Diagnosis
|
-- OR -- |
|
- “The degree of intra-individual or personal variation was from 3 to 31 per cent. This degree of variation was surprising to many, even to persons whose scientific training and background should have led them to anticipate it, in view of the known element of error in all fields.”
On the Scientific Evaluation of Diagnostic Procedures
L. Henry Garland
Radiology Vol. S2 March 1949 No. 3; page 309-328 - “The degree of inter-individual variation, based only on the positives and not on all cases read, was from 9 to 24 per cent. This variation included cases of extensive disease, and was not due to the fact that only small or difficult lesions were being analyzed. Variation can be measured in different ways. As an example, if in a set of 100 films there are 4 positive and 96 negative films and a reader selects only 2 of the positive, and calls the remaining 98 negative, he might be regarded, by one standard, as being only 2 per cent wrong or inconsistent. On the other hand, if the set of films consists of survey material, the object of which is to detect all the positives, he might be regarded as 50 per cent wrong. In the percentages recorded in these paragraphs, the second criterion is being used.”
On the Scientific Evaluation of Diagnostic Procedures
L. Henry Garland
Radiology Vol. S2 March 1949 No. 3; page 309-328 - “The degree of inter-individual variation, based only on the positives and not on all cases read, was from 9 to 24 per cent. This variation included cases of extensive disease, and was not due to the fact that only small or difficult lesions were being analyzed. Variation can be measured in different ways. As an example, if in a set of 100 films there are 4 positive and 96 negative films and a reader selects only 2 of the positive, and calls the remaining 98 negative, he might be regarded, by one standard, as being only 2 per cent wrong or inconsistent. On the other hand, if the set of films consists of survey material, the object of which is to detect all the positives, he might be regarded as 50 per cent wrong.”
On the Scientific Evaluation of Diagnostic Procedures
L. Henry Garland
Radiology Vol. S2 March 1949 No. 3; page 309-328
- “Pancreatic ductal adenocarcinoma (PDAC) is the most common primary pancreatic malignancy, ranking fourth in cancer-related mortality in the United States. Typically, PDAC appears on images as a hypovascular mass with upstream pancreatic duct dilatation and abrupt duct cutoff, distal pancreatic atrophy, and vascular encasement, with metastatic involvement including lymphadenopathy.However, atypical manifestations that may limit detection of the underlying PDAC may also occur. Atypical PDAC features include findings related to associated conditions such as acute or chronic pancreatitis, a mass that is isointense to the parenchyma, multiplicity, diffuse tumor infiltration, associated calcifications, and cystic components. Several neoplastic and inflammatory conditions can mimic PDAC, such as paraduodenal “groove” pancreatitis, autoimmune pancreatitis, focal acute and chronic pancreatitis,neuroendocrine tumors, solid pseudopapillary neoplasms, metastases, and lymphoma. Differentiation of these conditions from PDAC can be challenging due to overlapping CT and MRI features; however, certain findings can help in differentiation.”
Pancreatic Cancer and Its Mimics
Frank H. Miller, et al.
RadioGraphics 2023; 43(11):e230054 - “In the United States, PDAC accounts for 3.2% of all new cancer cases and 8% of all cancer deaths, ranking fourth in cancer-related mortality. Although surgery is the only curative treatment, at diagnosis an estimated 10%–20% of patients have resectable tumors, 30%–40% have borderline resectable or locally advanced or unresectable neoplasms, and 50%–60% have metastatic or systemic disease. PDAC is frequently detected late because of its nonspecific clinical presentation and lack of specific tumor markers and the limitations in imaging early-stage neoplasms, resulting in a poor prognosis.”
Pancreatic Cancer and Its Mimics
Frank H. Miller, et al.
RadioGraphics 2023; 43(11):e230054 - “AIP may be difficult to distinguish from PDAC at imaging because both can appear as a focal or infiltrative mass. Features favoring AIP include homogeneous enhancement during the portal venous phase, a hypointense capsulelike rim, extrapancreatic manifestations, the absence of pancreatic atrophy, and excellent response to steroid treatment.”
Pancreatic Cancer and Its Mimics
Frank H. Miller, et al.
RadioGraphics 2023; 43(11):e230054 - “Small neuroendocrine tumors can cause ductal dilatation and obstruction and upstream pancreatic atrophy secondary to secretion of serotonin and other metabolites, causing fibrotic narrowing of the main pancreatic duct. Marked pancreatic duct dilatation and stenosis and pancreatic atrophy out of proportion to an underlying hypervascular mass suggest a serotonin-producing PanNET.”
Pancreatic Cancer and Its Mimics
Frank H. Miller, et al.
RadioGraphics 2023; 43(11):e230054 - “The abrupt pancreatic duct cutoff sign is associated with a high incidence of PDAC. Gangi et al studied patients with pancreatic cancer who were asymptomatic before the diagnosis of cancer and found features suspicious for cancer in 50% of patients 2–18 months before diagnosis, including pancreatic duct dilatation with a cutoff. Johnston et al showed that 58% of patients identified with duct cut off received a diagnosis of malignancy, 62% of whom had PDAC.”
Pancreatic Cancer and Its Mimics
Frank H. Miller, et al.
RadioGraphics 2023; 43(11):e230054 - “Although most PDACs show classic imaging features, patients can present with atypical features that radiologists must recognize to avoid misdiagnosis. These atypical findings can relate to associated conditions such as acute or chronic pancreatitis and may limit detection of an underlying PDAC. Other atypical features include a mass that is isoattenuating to the parenchyma, multiplicity, diffuse tumor infiltration, associated calcifications, and cystic components.”
Pancreatic Cancer and Its Mimics
Frank H. Miller, et al.
RadioGraphics 2023; 43(11):e230054 - “The indirect signs of isoattenuating PDACs that provide clues to the diagnosis include upstream parenchymal atrophy, focal contour abnormality, mass effect, interrupted duct sign, and perivascular tumor infiltration. Secondary signs such as biliary and pancreatic duct dilatation are not seen in 14% of PDACs, especially those that are isoattenuating to the uncinate process and are present at an earlier stage compared with PDACs with secondary signs. Pancreatic tail tumors also are less likely to show pancreatic duct dilatation and instead show subtle changes in texture and loss of normal fatty lobulations that may indicate an underlying mass.”
Pancreatic Cancer and Its Mimics
Frank H. Miller, et al.
RadioGraphics 2023; 43(11):e230054 - "Diffuse infiltrating pancreatic lymphoma may mimic pancreatitis, while focal masslike lymphoma can mimic PDAC. Masslike lymphoma often occurs in the pancreatic head and, similar to PDAC, hypoenhances at CT and MRI compared with the background pancreas. Lymphomatous lesions tend to show mild to moderate homogeneous enhancement, are T1 hypointense and mildly T2 hyperintense, and restrict diffusion. Calcifications are uncommon in untreated lymphoma.”
Pancreatic Cancer and Its Mimics
Frank H. Miller, et al.
RadioGraphics 2023; 43(11):e230054 - “Metastases to the pancreas are rare, accounting for 2%–5% of pancreatic malignancies, and most commonly occur from renal cell carcinoma . Pancreatic metastatic disease may be a single tumor or multiple tumors, or it may involve the pancreas diffusely and have a variable appearance, depending on the primary site. Metastases from hypovascular or hypoenhancing primary malignancies (lung, breast, and colorectal cancer) can mimic PDAC, while hypervascular or arterially enhancing neoplasms (eg, renal cell carcinoma; melanoma; breast, thyroid, or hepatocellular carcinoma; and osteosarcoma) are typically hyperenhancing and multiple tumors, unlike PDACs.”
Pancreatic Cancer and Its Mimics
Frank H. Miller, et al.
RadioGraphics 2023; 43(11):e230054 - Solid pseudopapillary neoplasms, also referred to as solid and papillary epithelial neoplasms of the pancreas, are rare, accounting for 1%–2% of all pancreatic tumors . Unlike PDACs, solid pseudopapillary neoplasms tend to manifest in young women (mean age, 28.5 years at presentation) and show a low potential for malignant transformation. The behavior and prognosis of solid pseudopapillary neoplasms are generally favorable. Solid pseudopapillary neoplasms tend to be large at presentation (2.5–17.0 cm; mean size, 9 cm) and well defined , and they can be found throughout the pancreas. Large lesions can be distinguished from PDACs because they contain solid and cystic components due to hemorrhage, necrosis, and cystic degeneration.
Pancreatic Cancer and Its Mimics
Frank H. Miller, et al.
RadioGraphics 2023; 43(11):e230054 - “Compared with PDACs, solid pseudopapillary neoplasms often occur in younger patients. They are typically large at diagnosis, often associated with hemorrhage, and well defined and encapsulated, without metastases. Unlike PDACs, solid pseudopapillary neoplasms are less commonly associated with pancreatic and biliary duct dilatation, upstream parenchymal atrophy, or vascular invasion . Biopsy maybe required for definitive diagnosis.”
Pancreatic Cancer and Its Mimics
Frank H. Miller, et al.
RadioGraphics 2023; 43(11):e230054 - “At imaging, AIP may show three distinct patterns of pancreatic involvement: diffuse (70% of the pancreas), focal (up to 30% in type 1 and 80% in type 2), and multifocal (5%). Diffuse enlargement of the pancreas, with an enlarged tail, loss of normal lobulations, and a “sausage-shaped” appearance, and a capsule-like rim are the most classic imaging features of AIP, but they are only seen in 30%–40% of cases.”
Pancreatic Cancer and Its Mimics
Frank H. Miller, et al.
RadioGraphics 2023; 43(11):e230054 - “AIP may be difficult to distinguish from PDAC at imaging, because both can appear as focal or infiltrative mass. Features favoring AIP include homogeneous enhancement during the portal venous phase, a hypointense capsule-like rim, extrapancreatic manifestations , the absence of pancreatic atrophy, and excellent response to steroid treatment . Ductal findings favoring focal AIP include the “duct-penetrating” sign (best seen using secretin-enhanced MRCP); only mild dilatation of the main pancreatic duct, usually limited to an area of less than 4 mm; longer length of the narrowing of the main pancreatic duct (3 cm or more) in the involved segment of the pancreas, without an abrupt cutoff; the enhanced duct sign (wall enhancement of the main pancreatic duct in the lesion); multiple areas of narrowing or strictures of the main pancreatic duct; and the “icicle sign” (smoothly tapered narrowing of the upstream pancreatic duct) . When AIP is associated with biliary involvement, the imaging appearance can mimic primary sclerosing cholangitis. Multiple pancreatic lesions also favor a diagnosis of AIP over that of PDAC. Vascular encasement, fluid collections, or an increased number of lymph nodes are rare with AIP and favor a diagnosis of PDAC.”
Pancreatic Cancer and Its Mimics
Frank H. Miller, et al.
RadioGraphics 2023; 43(11):e230054 
Pancreatic Cancer and Its Mimics
Frank H. Miller, et al.
RadioGraphics 2023; 43(11):e230054
Pancreatic Cancer and Its Mimics
Frank H. Miller, et al.
RadioGraphics 2023; 43(11):e230054
Pancreatic Cancer and Its Mimics
Frank H. Miller, et al.
RadioGraphics 2023; 43(11):e230054
Pancreatic Cancer and Its Mimics
Frank H. Miller, et al.
RadioGraphics 2023; 43(11):e230054- Mimics of Pancreatic Cancer
- Mass-forming Chronic Pancreatitis
- Focal Acute Pancreatitis
- Paraduodenal Pancreatitis and Paraduodenal Cancer
- Autoimmune Pancreatitis
- Solid Pseudopapillary Neoplasm
- Metastases Involving the Pancreas
- Lymphoma
- IMPORTANCE Intravenous (IV) contrast medium is sometimes withheld due to risk of complication or lack of availability in patients undergoing computed tomography (CT) for abdominal pain. The risk from withholding contrast medium is understudied.
OBJECTIVE To determine the diagnostic accuracy of unenhanced abdominopelvic CT using contemporaneous contrast-enhanced CT as the reference standard in emergency department (ED) patients with acute abdominal pain.
CONCLUSION Unenhanced CT was approximately 30% less accurate than contrast-enhanced CT for evaluating abdominal pain in the ED. This should be balanced with the risk of administering contrast material to patients with risk factors for kidney injury or hypersensitivity reaction.
Diagnostic Accuracy of Unenhanced Computed Tomography for Evaluation of Acute Abdominal Painin the Emergency Department
Hiram Shaish et al
JAMA Surg. 2023;158(7):e231112. - “Unenhanced CT was approximately 30% less accurate than contrast-enhanced CT for evaluating abdominal pain in the ED. This should be balanced with the risk of administering contrast material to patients with risk factors for kidney injury or hypersensitivity reaction.”
Diagnostic Accuracy of Unenhanced Computed Tomography for Evaluation of Acute Abdominal Pain in the Emergency Department
Hiram Shaish et al
JAMA Surg. 2023;158(7):e231112. - Key Points
Question What is the diagnostic accuracy of unenhanced computed tomography (CT) in patients admitted to an emergency department with abdominal pain?
Findings In this multicenter diagnostic accuracy study, unenhanced CT was approximately 30 percentage points less accurate than contrast-enhanced CT for diagnosing the cause of pain and identifying actionable secondary diagnoses.
Meaning In a general population of emergency department patients with abdominal pain, using unenhanced CT to avoid risks of intravenous contrast medium administration was associated with a large diagnostic penalty.
Diagnostic Accuracy of Unenhanced Computed Tomography for Evaluation of Acute Abdominal Painin the Emergency Department
Hiram Shaish et al
JAMA Surg. 2023;158(7):e231112. - “False-negative (faculty, 13% to 19%; residents, 15%to 27%) and false-positive (faculty, 10% to 21%; residents, 8%to 19%) results were common at unenhanced CT for all radiologists. This likely was because reduced image contrast reduces accuracy and radiologist confidence. Example false-positive results included pancreatitis, bowel perforation, diverticulitis, pyelonephritis, and neoplasm. Example false-negative results included vascular dissection, hemoperitoneum, infection, and neoplasm. The commonality of both false-positive and false-negative results challenges efforts to adjust reading style to reduce error. In other words, the diagnostic penalty resulting from the elimination of contrast medium is not easily fixable by simply raising or lowering the threshold to report a diagnosis.”
Diagnostic Accuracy of Unenhanced Computed Tomography for Evaluation of Acute Abdominal Painin the Emergency Department
Hiram Shaish et al
JAMA Surg. 2023;158(7):e231112. - “We intentionally sampled a general population of ED patients with abdominal pain because dozens of diagnoses are commonly made with contrast-enhanced CT in that setting. Restricting the cohort to a specific diagnosis would have inflated the diagnostic accuracy. We subtracted oral, as well as IV, contrast medium from the reference standard to generate the unenhanced CT data. Diagnostic accuracy might have been higher had oral contrast medium been visible, or different had a single-energy unenhanced CT been used.”
Diagnostic Accuracy of Unenhanced Computed Tomography for Evaluation of Acute Abdominal Painin the Emergency Department
Hiram Shaish et al
JAMA Surg. 2023;158(7):e231112. - “In summary, unenhanced CT was approximately 30 percentage points less accurate than contrast- enhanced CT for the evaluation of abdominal pain in the ED. Prior studies evaluating unenhanced CT in this population likely have overstated its accuracy due to focus on 1 or few diagnoses or lack of a robust reference standard. The consistent results we observed across 3 centers suggest that the substantial diagnostic penalty we observed is likely to be related to the removal of contrast medium rather than to radiologist idiosyncrasy. For patients with risk factors for receiving iodinated contrast medium (eg, prior hypersensitivity reaction, severe kidney disease) or for patients receiving care in locations where contrast media is in short supply, the diagnostic risk of withholding contrast medium should be considered in the risk-benefit analysis. In many patients, the risk of with holding iodinated contrast medium may be higher than the risk of administering it.
Diagnostic Accuracy of Unenhanced Computed Tomography for Evaluation of Acute Abdominal Pain in the Emergency Department
Hiram Shaish et al
JAMA Surg. 2023;158(7):e231112. - “In summary, unenhanced CT was approximately 30 percentage points less accurate than contrast- enhanced CT for the evaluation of abdominal pain in the ED. Prior studies evaluating unenhanced CT in this population likely have overstated its accuracy due to focus on 1 or few diagnoses or lack of a robust reference standard. The consistent results we observed across 3 centers suggest that the substantial diagnostic penalty we observed is likely to be related to the removal of contrast medium rather than to radiologist idiosyncrasy.”
Diagnostic Accuracy of Unenhanced Computed Tomography for Evaluation of Acute Abdominal Pain in the Emergency Department
Hiram Shaish et al
JAMA Surg. 2023;158(7):e231112. - “Adding IV contrast material provides the benefit of increased diagnostic accuracy at the cost of potential adverse reactions like contrast-induced nephropathy, extravasation, and/or allergic reaction. The risk of kidney injury varies based on pre-CT kidney function: it approaches 0% with normal kidney function but is higher with chronically impaired kidney function. The rate of contrast extravasation is low(0.7%), and most extravasation events result in minimal to no long-term adverse effects. In a series of 69 657 IV contrast injections, 1 patient experienced extravasation of 75 mL of contrast into the hand. The risk of immediate hypersensitivity reactions into nonionic low-osmolar iodinated contrast media is 0.2% to 3% and lower for severe reactions.”
Intravenous Contrast in Computed Tomography Imaging for Acute Abdominal Pain
D. Dante Yeh, MD, MHPE; Courtney C. Moreno, MD; Mayur B. Patel, MD
JAMA Surgery July 2023 Volume 158, Number 7 - “For otherwise healthy individuals, the risk of a 30% loss in diagnostic accuracy if IV contrast material is withheld should be weighed against the exceedingly low risk of an adverse event. For patients with impaired kidney function or a history of prior severe allergic reaction, the risk-benefit balance may warrant withholding IV contrast. On the other hand, there are some diagnoses that one cannot see without IV contrast like an intravascular thrombus.”
Intravenous Contrast in Computed Tomography Imaging for Acute Abdominal Pain
D. Dante Yeh, MD, MHPE; Courtney C. Moreno, MD; Mayur B. Patel, MD
JAMA Surgery July 2023 Volume 158, Number 7 - “When we choose a noncontrast approach, we should be intentionally accepting diagnostic uncertainty, although this is already well accepted for certain diseases. For example, for patients with acute-onset flank pain with a high pretest probability for urolithiasis, omitting IV contrast is usually appropriate. However, there will always be patients with chronic kidney disease and anaphylactic allergic reactions and perhaps another national shortage. In these scenarios, we must ask ourselves: how much added value does the IV contrast provide against the risk of a missed and actionable acute diagnosis? In the low-risk patient, complications of IV contrast is often negligible, and the benefits of routine IV contrast far outweigh the risks.”
Intravenous Contrast in Computed Tomography Imaging for Acute Abdominal Pain
D. Dante Yeh, MD, MHPE; Courtney C. Moreno, MD; Mayur B. Patel, MD
JAMA Surgery July 2023 Volume 158, Number 7
- Background and Purpose: Medical errors can result in significant morbidity and mortality. The goal of our study is to evaluate correlation between shift volume and errors made by attending neuroradiologists at an academic medical center, using a large data set.
Materials and Methods: CT and MRI reports from our Neuroradiology Quality Assurance database (years 2014 2020) were searched for attending physician errors. Data were collected on shift volume, category of missed findings, error type, interpretation setting, exam type, clinical significance.
Conclusion: Errors were associated with higher volume shifts, were primarily perceptual and clinically significant. We need National guidelines establishing a range of what is a safe number of interpreted cross-sectional studies per day.
Impact of Shift Volume on Neuroradiology Diagnostic Errors at a Large Tertiary Academic Center
Vladimir Ivanovic et al.
Acad Radiol 2022 (in press) - Results: 654 reports contained diagnostic error. There was a significant difference between mean volume of interpreted studies on shifts when an error was made compared with shifts in which no error was documented (46.58 (SD=22.37) vs 34.09 (SD=18.60), p<0.00001); and between shifts when perceptual error was made compared with shifts when interpretive errors were made (49.50 (SD=21.9) vs 43.26 (SD=21.75), p=0.0094). 59.6% of errors occurred in the emergency/inpatient setting, 84% were perceptual and 91.1% clinically significant. Categorical distribution of errors was: vascular 25.8%, brain 23.4%, skull base 13.8%, spine 12.4%, head/neck 11.3%, fractures 10.2%, other 3.1%. Errors were detected most often on brain MRI (25.4%), head CT (18.7%), head/neck CTA (13.8%), spine MRI (13.7%).
Impact of Shift Volume on Neuroradiology Diagnostic Errors at a Large Tertiary Academic Center
Vladimir Ivanovic et al.
Acad Radiol 2022 (in press) - “There was a significant difference between mean volume of interpreted studies on shifts when an error was made compared with shifts in which no error was documented (46.58 (SD=22.37) vs 34.09 (SD=18.60), p<0.00001); and between shifts when perceptual error was made compared with shifts when interpretive errors were made (49.50 (SD=21.9) vs 43.26 (SD=21.75), p=0.0094). 59.6% of errors occurred in the emergency/inpatient setting, 84% were perceptual and 91.1% clinically significant.”
Impact of Shift Volume on Neuroradiology Diagnostic Errors at a Large Tertiary Academic Center
Vladimir Ivanovic et al.
Acad Radiol 2022 (in press) - “This study, diagnostic errors were found to significantly correlate with higher volume shifts. Most errors were perceptual, clinically significant and occurred in the emergency/inpatient setting (which tend to be our busiest shifts). To our knowledge, this study is the largest reported on neuroradiology attending physician errors, and our findings of association of busier shifts and errors is similar to other publications. In thoracic radiology, higher error rates have been associated with increasing number of interpreted studies per workday, or with decreased interpretation time per study. When interpreting abdominal CT studies, error rates more than double with increasing volume of interpreted studies.”
Impact of Shift Volume on Neuroradiology Diagnostic Errors at a Large Tertiary Academic Center
Vladimir Ivanovic et al.
Acad Radiol 2022 (in press) - “Our data suggests that a workflow adjustment aiming at limiting the number of studies per shift below a critical threshold might be beneficial in reducing error rate. Based on the findings of this study, we are considering instituting a ceiling of around 40 studies per day within our Neuroradiology Division once we are able to be fully staffed. Having to interpret CT/MRI exams in excess of the proposed institution-specific ceiling in a single shift may result in worsened patient and institutional outcomes based on the above published data.”
Impact of Shift Volume on Neuroradiology Diagnostic Errors at a Large Tertiary Academic Center
Vladimir Ivanovic et al.
Acad Radiol 2022 (in press) - “In conclusion, the majority of errors noted in our series occurred on higher volume shifts and were clinically significant. We need National guidelines establishing a range of what is asafe number of interpreted cross-sectional studies per day per radiologist, and the number of hours worked per shift.”
Impact of Shift Volume on Neuroradiology Diagnostic Errors at a Large Tertiary Academic Center
Vladimir Ivanovic et al.
Acad Radiol 2022 (in press)
- “Radiological errors can be classified according to the reporting process as pre-reporting, reporting or post- reporting errors. Pre-reporting errors consist of tech- nical issues and procedure-related problems, whereas post-reporting errors are mainly caused by poor communication between radiologists and clinicians. Reporting errors are directly related to radiologists and can be categorized into two parts. "Perceptual errors" are more common and related to the fact that the present finding is not noticed, while "interpretative errors" are influenced by cognitive biases that can contribute to false reasoning.”
Errors, discrepancies and underlying bias in radiology with case examples: a pictorial review
Omer Onder et al.
Insights Imaging (2021) 12:51 https://doi.org/10.1186/s13244-021-00986-8 - “Even in geographies that have a reputation for high quality care (such as metropolitan Boston and metropolitan New York) there is a five times greater chance of death from acute myocardial infarction (heart attack), depending on the hospital one chooses. Across the United States, on average, patients are twice as likely to die in the lowest-performing hospitals. This includes a 2.3-fold difference in heart attack mortalities. There are even greater differences in safety. The top 10% of hospitals are 10 times safer than bottom 10%. Patients are 18 times more likely to suffer a bloodstream infection from a central venous catheter when treated at poor-performing hospitals.”
4 Actions to Reduce Medical Errors in U.S> Hospitals
Troussaint JS, Segel KT
Harvard Business Review April 20, 2022 - 1. Make patient and staff safety a top priority
2.Establish a national safety organization
3. create a national reporting mechanism
4. turn on EHR’s machine leaning symptoms
4 Actions to Reduce Medical Errors in U.S> Hospitals
Troussaint JS, Segel KT
Harvard Business Review April 20, 2022 - “For early cancer detection, the percentage of confidence that comes with a diagnostic decision made by the algorithm might appear straightforward (for example, 80% confidence that lung cancer is present), but the process behind this number is very complex and understandably may not be apparent to the user. It is therefore not difficult to understand that there might be resistance to adoption of such strategies and the fear of overdiagnosis. It is important to understand that AI will not remove the need for physicians and experts to interpret the findings, provide a global picture of patient health, spot related diseases, and come up with a final diagnosis.”
The future of early cancer detection
Rebecca C. Fitzgerald et al.
Nature Medicine| VOL 28 | APRIL 2022 | 666–677 - "What the introduction of AI algorithms might do, providing that data management and safety regulations are in place, is reduce the cost and time needed to diagnose the disease. This will enable health practitioners to spend more time developing efficient and holistic treatment protocols, and will make state-of-art diagnostics more affordable. Furthermore, AI can be a training tool that provides immediate specialist feedback to generalists so that, in time, they may perform at an expert level.”
The future of early cancer detection
Rebecca C. Fitzgerald et al.
Nature Medicine| VOL 28 | APRIL 2022 | 666–677 
The future of early cancer detection
Rebecca C. Fitzgerald et al.
Nature Medicine| VOL 28 | APRIL 2022 | 666–677
The future of early cancer detection
Rebecca C. Fitzgerald et al.
Nature Medicine| VOL 28 | APRIL 2022 | 666–677
The future of early cancer detection
Rebecca C. Fitzgerald et al.
Nature Medicine| VOL 28 | APRIL 2022 | 666–677
- “Sarcoidosis is a chronic inflammatory dis- ease characterized by CD4+ T-cell activation and recruitment, macrophage accumulation, and development of sterile noncaseating epithelioid granulomas. Dominant expression of interferon is a defining feature of active sarcoidosis. The cause is not entirely clear and likely related to a complex interplay between environmental and genetic factors. Although the lungs are most commonly affected, nearly any organ in the body can be involved. Other commonly involved tissues include lymph nodes, skin, liver, and eyes.”
Sarcoidosis: A Diagnosis of Exclusion
Lee GM et al.
AJR 2020; 214:50–58 - "Sarcoidosis occurs worldwide and may af- fect men and women of all ages and races; however, sarcoidosis is most commonly seen in women, blacks, and individuals between the ages of 20–40 years old. First-degree relatives of patients with sarcoidosis are at increased risk for the disease. Furthermore, there is geographic variation in the prevalence of sarcoidosis, with highest prevalence observed in African Americans and Northern Europeans. Socioeconomic status does not affect the risk of developing sarcoidosis; however, financial barriers to medical care are associated with more severe manifestations at presentation.”
Sarcoidosis: A Diagnosis of Exclusion
Lee GM et al.
AJR 2020; 214:50–58 - “About half of all patients with sarcoidosis are asymptomatic at presentation, with imaging abnormalities detected incidentally on chest radiography performed for other reasons. When patients are symptomatic, the most common presenting thoracic symptom is persistent cough with other common symptoms including dyspnea, chest pain, wheezing, night sweats, and fatigue.”
Sarcoidosis: A Diagnosis of Exclusion
Lee GM et al.
AJR 2020; 214:50–58 - "In the United States and Europe, sarcoidosis-related death is most commonly attributable to pulmonary fibrosis with respiratory failure, whereas in Japan, cardiac lesions are found to be the leading contributor on autopsy. When abnormal, pulmonary function tests typically show a restrictive pattern with decreased carbon monoxide diffusing capacity. Pulmonary hypertension is a well-described complication of sarcoidosis, termed “sarcoidosis-associated pulmonary hypertension.”
Sarcoidosis: A Diagnosis of Exclusion
Lee GM et al.
AJR 2020; 214:50–58 - “The most common radiographic finding is well-defined mediastinal and hilar lymph adenopathy which occurs in an estimated 95% of cases. The classically described 1-2-3 pattern, also known as the Garland triad, is the combination of right paratracheal, right hilar, and left hilar lymph node enlargement. Additional studies have shown that the most common radiographic pattern shows left-sided mediastinal nodes, particularly aortico- pulmonary window lymph nodes, in addition to bilateral hilar and right paratracheal lymph nodes. This pattern is known as the more aptly named “1-2-3-4 pattern”.”
Sarcoidosis: A Diagnosis of Exclusion
Lee GM et al.
AJR 2020; 214:50–58 - "Thoracic sarcoidosis manifests with numerous patterns and nonspecific findings with a broad initial differential diagnosis including infectious, inflammatory, and neoplastic causes. Typical findings include hilar and right paratracheal lymphadenopathy and perilymphatic upper lung zone–predominant micronodules. However, in a significant minority of patients, the diagnosis is not straightforward. For this reason, sarcoidosis has been termed the “great mimicker.”
Sarcoidosis: A Diagnosis of Exclusion
Lee GM et al.
AJR 2020; 214:50–58
- “Sarcoidosis is a chronic inflammatory dis- ease characterized by CD4+ T-cell activation and recruitment, macrophage accumulation, and development of sterile noncaseating epithelioid granulomas. Dominant expression of interferon is a defining feature of active sarcoidosis. The cause is not entirely clear and likely related to a complex interplay between environmental and genetic factors. Although the lungs are most commonly affected, nearly any organ in the body can be involved. Other commonly involved tissues include lymph nodes, skin, liver, and eyes.”
Sarcoidosis: A Diagnosis of Exclusion
Lee GM et al.
AJR 2020; 214:50–58 - "Sarcoidosis occurs worldwide and may af- fect men and women of all ages and races; however, sarcoidosis is most commonly seen in women, blacks, and individuals between the ages of 20–40 years old. First-degree relatives of patients with sarcoidosis are at increased risk for the disease. Furthermore, there is geographic variation in the prevalence of sarcoidosis, with highest prevalence observed in African Americans and Northern Europeans. Socioeconomic status does not affect the risk of developing sarcoidosis; however, financial barriers to medical care are associated with more severe manifestations at presentation.”
Sarcoidosis: A Diagnosis of Exclusion
Lee GM et al.
AJR 2020; 214:50–58 - “About half of all patients with sarcoidosis are asymptomatic at presentation, with imaging abnormalities detected incidentally on chest radiography performed for other reasons. When patients are symptomatic, the most common presenting thoracic symptom is persistent cough with other common symptoms including dyspnea, chest pain, wheezing, night sweats, and fatigue.”
Sarcoidosis: A Diagnosis of Exclusion
Lee GM et al.
AJR 2020; 214:50–58 - "In the United States and Europe, sarcoidosis-related death is most commonly attributable to pulmonary fibrosis with respiratory failure, whereas in Japan, cardiac lesions are found to be the leading contributor on autopsy. When abnormal, pulmonary function tests typically show a restrictive pattern with decreased carbon monoxide diffusing capacity. Pulmonary hypertension is a well-described complication of sarcoidosis, termed “sarcoidosis-associated pulmonary hypertension.”
Sarcoidosis: A Diagnosis of Exclusion
Lee GM et al.
AJR 2020; 214:50–58 - “The most common radiographic finding is well-defined mediastinal and hilar lymph adenopathy which occurs in an estimated 95% of cases. The classically described 1-2-3 pattern, also known as the Garland triad, is the combination of right paratracheal, right hilar, and left hilar lymph node enlargement. Additional studies have shown that the most common radiographic pattern shows left-sided mediastinal nodes, particularly aortico- pulmonary window lymph nodes, in addition to bilateral hilar and right paratracheal lymph nodes. This pattern is known as the more aptly named “1-2-3-4 pattern”.”
Sarcoidosis: A Diagnosis of Exclusion
Lee GM et al.
AJR 2020; 214:50–58 - "Thoracic sarcoidosis manifests with numerous patterns and nonspecific findings with a broad initial differential diagnosis including infectious, inflammatory, and neoplastic causes. Typical findings include hilar and right paratracheal lymphadenopathy and perilymphatic upper lung zone–predominant micronodules. However, in a significant minority of patients, the diagnosis is not straightforward. For this reason, sarcoidosis has been termed the “great mimicker.”
Sarcoidosis: A Diagnosis of Exclusion
Lee GM et al.
AJR 2020; 214:50–58
- PURPOSE: This study is designed to test the authors’ hypothesis that radiologists’ reports from multiple imaging centers performing a lumbar MRI examination on the same patient over a short period of time will have (1) marked variability in interpretive findings and (2) a broad range of interpretive errors.
STUDY DESIGN: This is a prospective observational study comparing the interpretive findings reported for one patient scanned at 10 different MRI centers over a period of 3 weeks to each other and to reference MRI examinations performed immediately preceding and following the 10 MRI examinations.
PATIENT SAMPLE: The sample is a 63-year-old woman with a history of low back pain and right L5 radicular symptoms. - RESULTS: Across all 10 study examinations, there were 49 distinct findings reported related to the presence of a distinct pathology at a specific motion segment. Zero interpretive findings were reported in all 10 study examinations and only one finding was reported in nine out of 10 study examinations. Of the interpretive findings, 32.7% appeared only once across all 10 of the study examinations’ reports.
- CONCLUSIONS: This study found marked variability in the reported interpretive findings and a high prevalence of interpretive errors in radiologists’ reports of an MRI examination of the lumbar spine performed on the same patient at 10 different MRI centers over a short time period. As a result, the authors conclude that where a patient obtains his or her MRI examination and which radiologist in- terprets the examination may have a direct impact on radiological diagnosis, subsequent choice of treatment, and clinical outcome.
- “The primary purpose of scout views on cross-sectional CT and MRI examinations is to prescribe the imaging slices and display slice locations. For this reason, radiologists often ignore the scout images. However, it is not unusual for a pathologic abnormality to be visible on the initial scout images but then excluded from the subsequent diagnostic images, often because of the relatively larger FOV of the scout images. Scout views have been shown to contribute significantly to diagnosis. A systematic neglect of the scout views on cross-sectional imaging studies can result in important diagnoses being missed. A simple and effective remedy for this type of bias is to routinely review the scout images and include a field in the report template labeled “Scout views.”
Heuristics and Cognitive Error in Medical Imaging Itri JN, Patel SH AJR 2018; 210:1097–1105 - “Errors in radiology are broadly classified
into perceptual errors and interpretive errors. Perceptual errors account for 60–80% of errors and occur when an abnormality is present on a diagnostic image but not seen by the interpreting radiologist Interpretive errors constitute the remaining 20–40% of errors and occur when an abnormality is identified on an image but its meaning or importance is incorrectly interpreted.”
Heuristics and Cognitive Error in Medical Imaging Itri JN, Patel SH AJR 2018; 210:1097–1105 - “A heuristic is a mental shortcut that allows rapid problem solving based on assumptions and past experiences. Cognitive bias is a systematic error in reasoning or judgment that can be the result of failed heuristics. Cognitive biases can lead to both perceptual and interpretive errors. Perceptual error is an error that occurs when an abnormality is present on a diagnostic image but not seen by the interpreting radiologist. Interpretive error is an error that occurs when an abnormality is identified on an image but its meaning or importance is incorrectly interpreted. Diagnostic error is defined as a diagnosis that is missed, wrong, or delayed, which can be the result of either perceptual or interpretive errors.”
Heuristics and Cognitive Error in Medical Imaging Itri JN, Patel SH AJR 2018; 210:1097–1105 - “It has been observed that the detection rate for second and third abnormalities after one abnormality has been detected can decrease to approximately 50%, a cognitive bias termed “satisfaction of search”. This bias occurs when the visual search pattern is discontinued after identification of an abnormality that can explain the patient’s symptom and the interpreting radiologist is satisfied that the diagnosis has been determined.”
Heuristics and Cognitive Error in Medical Imaging Itri JN, Patel SH AJR 2018; 210:1097–1105 - “Diagnostic errors commonly arise from faulty heuristics and cognitive biases that all radiologists share. Such biases can produce predictable patterns of misdiagnoses. Awareness of the spectrum of cognitive biases is an important step toward a comprehensive strategy to learn from diagnostic errors and ultimately improve patient care.”
Heuristics and Cognitive Error in Medical Imaging Itri JN, Patel SH AJR 2018; 210:1097–1105 - “The practice of reinterpreting imaging ex- aminations performed at outside institutions is becoming commonplace at academic centers because of a relatively high rate of discrepancies affecting patient care. Error rates as high as 41% have been reported during the reinterpretation of outside CT and MRI examinations in patients with head and neck cancer at an academic center.”
Heuristics and Cognitive Error in Medical Imaging Itri JN, Patel SH AJR 2018; 210:1097–1105 - “Availability bias refers to the tendency for diagnostic assessments to be unduly influenced by easily recalled experiences
For radiologists, memorable cases can exert an undue effect on the interpretation of sub- sequent cases. Prior cases may be easier to recall if they were recently interpreted, associated with an unusual diagnosis, or associated with a personal error. Such cases may exert a disproportionate effect on diagnostic thinking compared with other more-routine cases or cases from the remote past.”
Heuristics and Cognitive Error in Medical Imaging Itri JN, Patel SH AJR 2018; 210:1097–1105
- “Medical errors are a leading cause of morbidity and mortality in the medical field and are substantial contributors to medical costs. Radiologists play an integral role in the diagnosis and care of patients and, given that those in this field interpret millions of examinations annually, may therefore contribute to diagnostic errors. Errors can be categorized as a “miss” when a primary or critical finding is not observed or as a “misinterpretation” when errors in interpretation lead to an incorrect diagnosis.”
Bias in Radiology: The How and Why of Misses and Misinterpretations Busby LP et al. RadioGraphics 2018; 38:236–247 - “Diagnostic errors can be defined as errors that result in incorrect, delayed, or missed diagnoses. In malpractice lawsuits led against radiologists, approximately 75% of lawsuits relate to diagnostic errors, and 38% of money paid in general malpractice lawsuits results from diagnostic errors.”
Bias in Radiology: The How and Why of Misses and Misinterpretations Busby LP et al. RadioGraphics 2018; 38:236–247 - “Systemic sources of error that can impact cognitive processes should be addressed through institutional measures, including limiting unnecessary interruptions during imaging interpretation and providing radiologists with diagnostic feedback through peer-review programs, quality improvement, and radiologic-pathologic correlation.”
Bias in Radiology: The How and Why of Misses and Misinterpretations Busby LP et al. RadioGraphics 2018; 38:236–247 
- “Satisfaction of search refers to an individual’s decreased vigilance and/or awareness of additional abnormalities after the first abnormality has been identified This is a bias that plagues radiologists. In a study classifying types of radiologic diagnostic errors, 22% were related to satisfaction of search, which was second only to errors classified as underdiagnoses or misses, making this the most common cognitive bias in diagnostic radiology.”
Bias in Radiology: The How and Why of Misses and Misinterpretations Busby LP et al. RadioGraphics 2018; 38:236–247 - “Radiologists can use a systematic approach to ensure all relevant findings are identified, particularly common and commonly missed diagnoses. After completing the primary search and identifying the first finding or responding to the clinical question, one should initiate a secondary search. Related diagnoses and common diagnostic combinations should be kept in the forefront of the search.”
Bias in Radiology: The How and Why of Misses and Misinterpretations Busby LP et al. RadioGraphics 2018;38:236–247 - “Prevalent in all medical specialties, hindsight bias is the tendency to retrospectively de-emphasize the difficulty in making the initial diagnosis after it has been confirmed particularly in morbidity and mortality conferences. This bias is also referred to as the “I knew it all along” bias, retrospectoscope bias, or the “how could he/she miss that?” bias. It is distinct from previously described biases due to its retrospective nature. Hindsight bias prevents the realistic assessment of past events, distorts the evaluation of prior decision making, and discounts the scenario under which the decision making occurred. This bias is related to self-serving bias in that individuals are more likely to take credit for their correct decisions and discount their mistakes.”
Bias in Radiology: The How and Why of Misses and Misinterpretations Busby LP et al. RadioGraphics 2018; 38:236–247 - “Prevalent in all medical specialties, hindsight bias is the tendency to retrospectively de-emphasize the difficulty in making the initial diagnosis after it has been confirmed particularly in morbidity and mortality conferences. This bias is also referred to as the “I knew it all along” bias, retrospectoscope bias, or the “how could he/she miss that?” bias. It is distinct from previously described biases due to its retrospective nature. Hindsight bias prevents the realistic assessment of past events, distorts the evaluation of prior decision making, and discounts the scenario under which the decision making occurred.”
Bias in Radiology: The How and Why of Misses and Misinterpretations Busby LP et al. RadioGraphics 2018; 38:236–247 - Systemic Sources and Solutions
• Workplace Interruptions
• Quality Assurance and Peer Review.
• Radiologic-Pathologic Correlation - “As such, interruptions can contribute to all cognitive biases, particularly satisfaction of search and premature closure. Implementing strategies to reduce work flow disruption, such as designating an individual to manage noninterpretive tasks, has been successful in increasing interpretation time and decreasing disruptions.”
Bias in Radiology: The How and Why of Misses and Misinterpretations Busby LP et al. RadioGraphics 2018; 38:236–247 - “Creating a peer-review program with a positive culture is essential to correct cognitive bias. Peer-review programs establish an environment where errors are instructive rather than punitive and support an atmosphere of cognitive debiasing, ensuring that hindsight bias does not overwhelm the retrospective analyses. It is important to acknowledge both hits and misses throughout this process, as sharing and discussing positive calls, in addition to missed findings, helps foster a positive environment for analyzing clinical decisions.”
Bias in Radiology: The How and Why of Misses and Misinterpretations Busby LP et al. RadioGraphics 2018; 38:236–247 - “Routine radiologic-pathologic correlation is the current standard of care in breast imaging. It has the potential for positive implications on cognitive training for all involved when radiologic diagnoses have pathologic correlates. Radiologic-pathologic correlation gives a diagnostic radiologist accurate feedback on his or her disease detection rates, positive predictive values, and abnormal interpretation rates. This establishes the radiologist’s knowledge of base rates of disease and therefore helps increase awareness and prevention of availability bias.”
Bias in Radiology: The How and Why of Misses and Misinterpretations Busby LP et al. RadioGraphics 2018; 38:236–247 - “Cognitive forcing strategies and metacognition can help disrupt and reduce the impact of cognitive bias on decision making and decrease rates of diagnostic error. Systemic sources of error that can impact cognitive processes should be addressed through institutional measures, including limiting unnecessary interruptions during imaging interpretation and providing radiologists with diagnostic feedback through peer-review programs, quality improvement, and radiologic-pathologic correlation. Being aware of the limitations in one’s judgment can lead to more thoughtful deliberation of imaging findings and improve the quality of decision making.”
Bias in Radiology: The How and Why of Misses and Misinterpretations Busby LP et al. RadioGraphics 2018; 38:236–247
- “As such, interruptions can contribute to all cognitive biases, particularly satisfaction of search and premature closure. Implementing strategies to reduce work flow disruption, such as designating an individual to manage noninterpretive tasks, has been successful in increasing interpretation time and decreasing disruptions.”
Bias in Radiology: The How and Why of Misses and Misinterpretations Busby LP et al. RadioGraphics 2018; 38:236–247 - “Creating a peer-review program with a positive culture is essential to correct cognitive bias. Peer-review programs establish an environment where errors are instructive rather than punitive and support an atmosphere of cognitive debiasing, ensuring that hindsight bias does not overwhelm the retrospective analyses. It is important to acknowledge both hits and misses throughout this process, as sharing and discussing positive calls, in addition to missed findings, helps foster a positive environment for analyzing clinical decisions.”
Bias in Radiology: The How and Why of Misses and Misinterpretations Busby LP et al. RadioGraphics 2018; 38:236–247 - “Routine radiologic-pathologic correlation is the current standard of care in breast imaging. It has the potential for positive implications on cognitive training for all involved when radiologic diagnoses have pathologic correlates. Radiologic-pathologic correlation gives a diagnostic radiologist accurate feedback on his or her disease detection rates, positive predictive values, and abnormal interpretation rates. This establishes the radiologist’s knowledge of base rates of disease and therefore helps increase awareness and prevention of availability bias.”
Bias in Radiology: The How and Why of Misses and Misinterpretations Busby LP et al. RadioGraphics 2018; 38:236–247 - “Cognitive forcing strategies and metacognition can help disrupt and reduce the impact of cognitive bias on decision making and decrease rates of diagnostic error. Systemic sources of error that can impact cognitive processes should be addressed through institutional measures, including limiting unnecessary interruptions during imaging interpretation and providing radiologists with diagnostic feedback through peer-review programs, quality improvement, and radiologic-pathologic correlation. Being aware of the limitations in one’s judgment can lead to more thoughtful deliberation of imaging findings and improve the quality of decision making.”
Bias in Radiology: The How and Why of Misses and Misinterpretations Busby LP et al. RadioGraphics 2018; 38:236–247
- “For comprehensive improvements to health care delivery, other failures in the cycle besides diagnostic interpretive error—such as ordering inappropriate studies, PACS failures, and a lack of accurate clinician contact information (with resultant communication failure)—should be recognized as contributors to patient harm because they lead to wasted resources and delayed care. By taking ownership of the entire imaging cycle, radiologists can increase their net worth to patient care and cement their roles as experts in the effective, evidence-based use of imaging technologies.”
Systemic Error in Radiology. Waite S, Scott JM, Legasto A et al. AJR Am J Roentgenol. 2017 Sep;209(3):629-639 - “Although interpretative errors related to faulty visual detection, pattern recognition, or cognitive reasoning are the most common cause of malpractice litigation against radiologists , Jones et al. found that more than 62% of errors, incidents (defined as an event or circumstance that may have resulted in unnecessary patient harm), and process failures occur in other phases of the cycle.”
Systemic Error in Radiology. Waite S, Scott JM, Legasto A et al. AJR Am J Roentgenol. 2017 Sep;209(3):629-639 - “Communication errors are the third most common cause of malpractice against radiol- ogists after diagnostic errors and procedural complications. Although most studies of communication failures in radiology focus on results communication, 52.4% of communica- tion errors occur during the ordering, sched- uling, and performance of an imaging ex- amination.”
Systemic Error in Radiology. Waite S, Scott JM, Legasto A et al. AJR Am J Roentgenol. 2017 Sep;209(3):629-639 - “For comprehensive improvements to health care delivery, other failures in the cycle besides diagnostic interpretive error— such as inappropriate imaging, PACS failures, and a lack of accurate clinician contact information (with resultant communication failure)—should be recognized as contributors to patient harm because they lead to wasted resources and delayed care. By taking ownership of the entire imaging cycle, radiologists can increase their net worth to patient care and cement their roles as experts in the effective, evidence-based use of imaging technologies.”
Systemic Error in Radiology. Waite S, Scott JM, Legasto A et al. AJR Am J Roentgenol. 2017 Sep;209(3):629-639 - “By taking ownership of the entire imaging cycle, radiologists can increase their net worth to patient care and cement their roles as experts in the effective, evidence-based use of imaging technologies.”
Systemic Error in Radiology. Waite S, Scott JM, Legasto A et al. AJR Am J Roentgenol. 2017 Sep;209(3):629-639
- “Radiologists use visual detection, pattern recognition, memory, and cognitive reasoning to synthesize final interpretations of radiologic studies. This synthesis is performed in an environment in which there are numerous extrinsic distractors, increasing workloads and fatigue. Given the ultimately human task of perception, some degree of error is likely inevitable even with experienced observers. However, an understanding of the causes of interpretive errors can help in the development of tools to mitigate errors and improve patient safety.”
Interpretive Error in Radiology Waite S et al. AJR 2017; 208:739–749 - “It is postulated that when analyzing a radiologic study, there is rapid identi cation of abnormalities using peripheral vision with subsequent scrutiny utilizing central vision. Radiologists compare this “gist” impression with information contained in long-term memory that forms the viewer’s cognitive schema (or expectations) of what information is in an image. This rapid response is shown when a radiologist identifies subtle abnormalities on mammography and chest radiography in only 250 ms.”
Interpretive Error in Radiology Waite S et al. AJR 2017; 208:739–749 - “Differences in attentional processing explain the variations in search patterns between experts and novices. Expert radiologists know where to look for nodules, which limits inspection of many irrelevant areas. Other regions may not be scrutinized because they lack concerning preattentive attributes.”
I
nterpretive Error in Radiology Waite S et al. AJR 2017; 208:739–749 - “Radiologists use visual detection, pattern recognition, memory, and cognitive reasoning to synthesize final interpretations of radiologic studies. This synthesis is performed in an environment in which there are numerous extrinsic distractors increasing workloads and fatigue. Given the ultimately human task of perception, some degree of error is likely inevitable even with experienced observers. However, an understanding of the causes of interpretive errors can help in the development of tools to mitigate errors and improve patient safety.”
Interpretive Error in Radiology Waite S et al. AJR 2017; 208:739–749 - “A long-recognized method to reduce error in interpretation is to have “ films interpreted independently by two readers”. Double reading is not practiced consistently in the United States because it is time-consuming and the second read is not reimbursed. Because of the time commitment and lack of financial compensation, double reading should be reserved for complex cases in which a second opinion will provide a substantial benefit. Furthermore, the process must be rapid, and mechanisms to reconcile discrepancies between readers should be clearly defined.”
Interpretive Error in Radiology Waite S et al. AJR 2017; 208:739–749 - “Computer-aided detection (CAD) refers to pattern recognition software that ags suspicious features on an image in an attempt to decrease false-negative readings.The radiologist reviews the examination and the CAD-marked areas of concern before issuing a final .CAD systems do not mark all actionable findings; therefore, the absence of a CAD mark on a finding should not preclude evaluation. In addition, current CAD systems generate more false findings than true findings. The radiologist must determine whether a CAD mark warrants further. The difficulty in discriminating between true- and
false-positive marks is the biggest current challenge in CAD software. CAD is currently used and studied most widely in mammography but is also used in chest imaging and other modalities.”
Interpretive Error in Radiology Waite S et al. AJR 2017; 208:739–749
- “BACKGROUND CONTEXT: In today’s health-care climate, magnetic resonance imaging (MRI) is often perceived as a commodity—a service where there are no meaningful differences in quality and thus an area in which patients can be advised to select a provider based on price and convenience alone. If this prevailing view is correct, then a patient should expect to receive the same radiological diagnosis regardless of which imaging center he or she visits, or which radiologist reviews the examination. Based on their extensive clinical experience, the authors believe that this assumption is not correct and that it can negatively impact patient care, outcomes, and costs.”
Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period Herzog R et al. The Spine Journal (in press) - “Across all 10 study examinations, there were 49 distinct findings reported related to the presence of a distinct pathology at a specific motion segment. Zero interpretive findings were reported in all 10 study examinations and only one finding was reported in nine out of 10 study examinations. Of the interpretive findings, 32.7% appeared only once across all 10 of the study examinations' reports. A global Fleiss kappa statistic, computed across all reported findings, was 0.20±0.06, indicating poor overall agreement on interpretive findings. The average interpretive error count in the study examinations was 12.5±3.2 (both false-positives and false-negatives). The average false-negative count per examination was 10.9±2.9 out of 25 and the average false-positive count was 1.6±0.9, which correspond to an average true-positive rate (sensitivity) of 56.4%±11.7 and miss rate of 43.6%±11.7.”
Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period Herzog R et al. The Spine Journal (in press) - “Across all 10 study examinations, there were 49 distinct findings reported related to the presence of a distinct pathology at a specific motion segment. Zero interpretive findings were reported in all 10 study examinations and only one finding was reported in nine out of 10 study examinations. Of the interpretive findings, 32.7% appeared only once across all 10 of the study examinations' reports. A global Fleiss kappa statistic, computed across all reported findings, was 0.20±0.06, indicating poor overall agreement on interpretive findings.”
Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period Herzog R et al. The Spine Journal (in press) - “Ultimately, it is the authors' opinions that accurate and complete diagnostic information at the onset of an injury or illness is critical to improve the chances for a patient's full recovery. However, reducing diagnostic errors and variability in reported findings will require the development and adoption of systematic mechanisms for measuring diagnostic MRI quality, including error rates. The authors acknowledge that accurately measuring interpretive errors at scale is a significant challenge and that some health-care providers may be reluctant to adopt such a system due to concerns around exposure of their errors, negative impact on reimbursement, and potential liability.”
Variability in diagnostic error rates of 10 MRI centers performing lumbar spine MRI examinations on the same patient within a 3-week period Herzog R et al. The Spine Journal (in press) 
- “Radiologists use visual detection, pattern recognition, memory, and cognitive reasoning to synthesize final interpretations of radiologic studies. This synthesis is performed in an environment in which there are numerous extrinsic distractors, increasing workloads and fatigue. Given the ultimately human task of perception, some degree of error is likely inevitable even with experienced observers. However, an understanding of the causes of interpretive errors can help in the development of tools to mitigate errors and improve patient safety.”
Interpretive Error in Radiology. Waite S et al. AJR Am J Roentgenol 2016 Dec 27:1-11 - “In 1949, Garland [8] found a 33.3% error rate in the interpretation of positive lms based on group consensus opinion and an 8% intrareader variation (when a reader disagrees with him or herself when rereading a study). This rate of error has remained virtually unchanged. In a mix of abnormal and normal studies representative of a typical clinical practice, the error rate is approximately 4%.”
Interpretive Error in Radiology. Waite S et al. AJR Am J Roentgenol 2016 Dec 27:1-11 - “A recognition error is a failure of the ba- sic mechanism of object recognition; the radiologist fixates on the target for a duration shorter than the threshold dwell time considered sufficient to recognize lesion features . The threshold for lesion detection depends on the imaging modality and ranges from 500 to 1000 ms . Both search and recognition errors are considered perceptual errors.”
Interpretive Error in Radiology. Waite S et al. AJR Am J Roentgenol 2016 Dec 27:1-11 - “Sokolovskaya et al. reported that when radiologists were asked to interpret studies at twice their baseline speed, the number of major misses increased from 10% to 26.6%. Because re- imbursement in many practices is based on productivity, there is a strong financial incentive to read as many studies—without breaks—as possible. A sustained artificially high interpretative rate can result in additional interpretive errors from both general and oculomotor fatigue.”
Interpretive Error in Radiology. Waite S et al. AJR Am J Roentgenol 2016 Dec 27:1-11 - “Radiologists use visual detection, pattern recognition, memory, and cognitive reasoning to synthesize final interpretations of radiologic studies. This synthesis is performed in an environment in which there are numerous extrinsic distractors increasing workloads and fatigue. Given the ultimately human task of perception, some degree of error is likely inevitable even with experienced observers. However, an understanding of the causes of interpretive errors can help in the development of tools to mitigate errors and improve patient safety.”
Interpretive Error in Radiology. Waite S et al. AJR Am J Roentgenol 2016 Dec 27:1-11
- “Radiology departments are encouraged to develop reliable means of identifying challenging and missed diagnoses and using these cases as an education resource in an ongoing effort to mitigate misdiagnosis. A monthly CME conference with pathology and/or surgical correlation and clinical follow-up is an excellent means of providing meaningful peer review to improve practice of the entire division and reduce interpretative errors.”
Mitigating Misdiagnosis in Radiology: Educational CT CME Case Conference for Peer Review and Interpretative Improvement Pamela T. Johnson, MD, , David Badger, MD, Karen M. Horton, MD, Elliot K. Fishman, MD JACR: Volume 13, Issue 10, October 2016, Pages 1244–1246 - “Technological advances in body CT have improved our abilities to identify and characterize abnormalities. Unprecedented spatial, contrast, and temporal resolution furnish new opportunities for early disease detection, but despite superior image quality, diagnostic errors persist. Misdiagnoses can be caused by suboptimal protocol design to elucidate pathology, failure to identify a finding, or failure to accurately characterize an abnormality.”
Mitigating Misdiagnosis in Radiology: Educational CT CME Case Conference for Peer Review and Interpretative Improvement Pamela T. Johnson, MD, , David Badger, MD, Karen M. Horton, MD, Elliot K. Fishman, MD JACR: Volume 13, Issue 10, October 2016, Pages 1244–1246 - “As opposed to standard peer review, where the reviewing radiologist informs the primary reader that he or she believes a diagnosis was missed or an interpretation provided the wrong information, a CT case conference that includes correlation with other diagnostic information (pathology, surgical findings, clinical follow-up) provides accurate peer review based on gold standards, from which everyone in the division can learn to improve their interpretative skills.”
Mitigating Misdiagnosis in Radiology: Educational CT CME Case Conference for Peer Review and Interpretative Improvement Pamela T. Johnson, MD, , David Badger, MD, Karen M. Horton, MD, Elliot K. Fishman, MD JACR: Volume 13, Issue 10, October 2016, Pages 1244–1246 - “Radiology departments are encouraged to develop reliable means of identifying challenging and missed diagnoses and using these cases as an education resource in an ongoing effort to mitigate misdiagnosis. A monthly CME conference with pathology and/or surgical correlation and clinical follow-up is an excellent means of providing meaningful peer review to improve practice of the entire division and reduce interpretative errors.”
Mitigating Misdiagnosis in Radiology: Educational CT CME Case Conference for Peer Review and Interpretative Improvement Pamela T. Johnson, MD, , David Badger, MD, Karen M. Horton, MD, Elliot K. Fishman, MD JACR: Volume 13, Issue 10, October 2016, Pages 1244–1246
- “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.”
Diagnostic errors in abdominopelvic CT interpretation: characterization based on report addenda Andrew B. Rosenkrantz, Neil K. Bansal Abdom Radiol (2016) 41:1793–1799 - “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.” Diagnostic errors in abdominopelvic CT interpretation: characterization based on report addenda Andrew B. Rosenkrantz, Neil K. Bansal Abdom Radiol (2016) 41:1793–1799
- Adrenal Gland Imaging: Pitfalls
Pseudolesions
accessory spleen
celiac plexus
lymph nodes
gastric fundal diverticula,
venous varices
renal lesions - Adrenal Gland Imaging: Pitfalls
- Pheochromocytoma is a great mimicker especially when it presents as an incidental finding
- Collision tumors that have been defined as representing 2 pathologically distinct lesions (such as a benign and a malignant lesion), giving the appearance of a single lesion. The benign features of portions of a conglomerate lesion (ie, intralesional lipid) could lead to the false conclusion that the entire mass is benign. - Adrenal Gland Imaging: Pitfalls
- Metastases to the adrenal from renal cell carcinoma or hepatoma can be confused with pheochromocytoma or even adenoma based on washout values.
- Macroscopic fat in an adrenal mass is effectively diagnostic of adrenal myelolipoma; however, smaller amounts of fat can be present within myelolipomatous metaplasia of adrenal cortical neoplasms such as degenerated adenomas and adrenal cortical carcinomas. - “Although incidentally detected adrenal nodules are most commonly benign adrenal adenomas, accurate imaging char- acterization is important, as the risk of malignancy increases substantially in patients with a history of primary malignancy and in adrenal nodules measuring more than 4 cm.”
Pitfalls in Adrenal Imaging Taner AT et al. Semin Roentgenol. 2015 Oct;50(4):260-72. - “Although the typical radiological appear- ances of common pancreatic lesions is well known, there are several potential pitfalls that can be encountered in pancreatic imaging, such as pancreatic anatomical variants mimicking pancreatic lesions, inflammatory conditions mimicking malignancy, atypical radiological appearance of pancreatic adenocarcinoma, and cystic pancreatic lesions and peripancreatic lesions mimicking intrapancreatic lesions.”
Pitfalls in pancreatic imaging Kaza RK et al. Semin Roentgenol. 2015 Oct;50(4):320-7 - “Anatomical variants of the pancreas resulting from anomalies in fusion (pancreas divisum) or migration (annular or ectopic pancreas) are easily recognized by their typical radiological appearance. However, other developmental anomalies such as heterogeneous fatty infiltration, anatomical variants in the shape and contour of the pancreas, and benign intrapancreatic masses such as splenule can mimic pancreatic malignancies.”
Pitfalls in pancreatic imaging Kaza RK et al. Semin Roentgenol. 2015 Oct;50(4):320-7 - “In all, 4 different patterns of fatty infiltration of pancreas have been described, of which focal fatty infiltration or sparing of the head and/or uncinate process of the pancreas is the common entity mimicking a pancreatic mass. On contrast-enhanced CT, the area of fatty infiltration appears hypodense to pancreatic parenchyma, mimicking a mass. However, the lack of biliary and pancreatic ductal obstruction or mass effect on adjacent vessels, maintained lobu- lated pancreatic contour, and typical distribution with sparing of peribiliary region can suggest the correct diagnosis of fatty infiltration.”
Pitfalls in pancreatic imaging Kaza RK et al. Semin Roentgenol. 2015 Oct;50(4):320-7 - “Alteration of pancreatic contour with anterior or lateral extension of pancreatic parenchyma from the head of the pancreas or a lobulated appearance of tail can give the appearance of a pseudomass of the pancreas. Enhancement of the lobulated “masslike” area, being similar to the rest of pancreatic parenchyma; review of images in coronal and sagittal planes showing the lobulated outline of the pancreatic parenchyma; and lack of effacement of the interdigitating fat in the same location are helpful in avoiding this misdiagnosis.”
Pitfalls in pancreatic imaging Kaza RK et al. Semin Roentgenol. 2015 Oct;50(4):320-7 - “Accessory splenic tissue within pancreatic parenchyma is seen within 3 cm from the distal end of the pancreatic tail and can mimic a solid pancreatic neoplasm. Because of its well-defined margin and homogenous enhancement on portal venous phase, intrapancreatic accessory spleen (IPAS) can be misdiagnosed as a neuroendocrine tumor of the pancreas.”
Pitfalls in pancreatic imaging Kaza RK et al. Semin Roentgenol. 2015 Oct;50(4):320-7 - “Uncommon variants of pancreatitis such as autoimmune pancreatitis (AIP), focal or groove pancreatitis, and mass-forming chronic pancreatitis can mimic pancreatic adenocarcinoma, leading in some cases to unwarranted surgery to exclude underlying malignancy.”
Pitfalls in pancreatic imaging Kaza RK et al. Semin Roentgenol. 2015 Oct;50(4):320-7 - “Radiological features that could suggest a diagnosis of groove pancreatitis include circumferential duodenal wall thickening with cystic changes in the wall of the duodenum and smooth narrowing of the pancreatic duct and the common bile duct, whereas abrupt duct cutoff and presence of vascular invasion would suggest a diagnosis of pancreatic adenocarcinoma.”
Pitfalls in pancreatic imaging Kaza RK et al. Semin Roentgenol. 2015 Oct;50(4):320-7 - “Groove pancreatitis or paraduodenal pancreatitis is a form of focal chronic pancreatitis involving the potential space between the duodenum, head of the pancreas, and the common bile duct. Inflammatory changes and fibrosis can be seen involving only the groove region (pure form) or the pancreatic head, with extension into the pancreaticoduodenal groove (segmental form). Groove pancreatitis can mimic pancreatic adenocarcinoma involving the head of the pancreas, as both the entities show significant overlap in presentation and imaging findings and both are relatively hypovascular and show delayed enhancement on contrast-enhanced CT.”
Pitfalls in pancreatic imaging Kaza RK et al. Semin Roentgenol. 2015 Oct;50(4):320-7 - “The possibility of pancreatic carcinoma developing in the setting of chronic pancreatitis makes it important to try to distinguish between the 2 entities. Although radiological features such as smooth narrowing of the pancreatic duct or normal pancreatic duct and absence of peripancreatic vascular involvement favor a diagnosis of chronic pancreatitis, an EUS and biopsy are usually needed to exclude pancreatic ductal adenocarcinoma.”
Pitfalls in pancreatic imaging Kaza RK et al. Semin Roentgenol. 2015 Oct;50(4):320-7 - “Approximately 5%-10% of PNETs can undergo cystic degeneration and mimic a true cystic pancreatic lesion. However, cystic PNETs have a thick enhancing rim along the periphery, representing a portion of the tumor that has not undergone cystic degeneration, enabling its differentiation from other cystic pancreatic lesions. A pancreatic adenocarcinoma with large areas of necrosis or a solid pseudopapillary neoplasm of the pancreas with areas of hemorrhage and necrosis can be mistaken for a heterogeneous cystic pancreatic neoplasm.”
Pitfalls in pancreatic imaging Kaza RK et al. Semin Roentgenol. 2015 Oct;50(4):320-7 - “Approximately 10% of PDAs can appear isoattenuating to the adjacent pancreatic parenchyma on multidetector CT during both the pancreatic parenchymal and the portal venous phases, making it difficult to identify the tumor on imaging. Presence of other indirect signs of PDA, such as upstream pancreatic (“interrupted pancreatic duct”) or biliary ductal dilation with or without parenchymal atrophy would suggest the possibility of an underlying mass, even though one may not be seen.”
Pitfalls in pancreatic imaging Kaza RK et al. Semin Roentgenol. 2015 Oct;50(4):320-7 - “Primary bowel masses arising from the stomach, duodenum, or jejunum that have an exophytic component can mimic pancreatic masses. An exophytic gastrointestinal tumor arising from the duodenum can mimic a pancreatic neuroendocrine tumor, considering the heterogeneous enhancement and well-circumscribed nature of both these tumors. A fluid-filled or collapsed duodenal diverticulum could mimic a hypodense pancreatic mass. Ensuring adequate bowel distension while imaging and multiplanar image review would be helpful in making the correct diagnosis.”
Pitfalls in pancreatic imaging Kaza RK et al. Semin Roentgenol. 2015 Oct;50(4):320-7 - “Recognition of the atypical radiological presentations of pancreatic pathologic processes, use of optimal imaging techniques such as biphasic imaging of the pancreas (pancreatic parenchymal and portal venous phases) and thin-slice multiplanar reconstruction, and further evaluation with EUS and biopsy in indeterminate cases would help avoiding pitfalls in diagnosis of benign and malignant lesions of the pancreas.” Pitfalls in pancreatic imaging Kaza RK et al. Semin Roentgenol. 2015 Oct;50(4):320-7
- Peripancreatic Lesions Mimicking Pancreatic Lesions
- Aneurysms or pseudoaneuryms
- Small bowel tumors or just normal bowel
- Adenopathy
- Retroperitoneal masses
- “Participation in the peer review process is one means by which errors in radiology diagnosis can be identified, but the effectiveness of these programs is hampered by physicians’ reluctance to implicate their colleagues in misdiagnosis. Survey data show that nonanonymized peer review increases anxiety, raises concerns over malpractice and job security, and has the potential to strain relationships with colleagues.”
Mitigating Misdiagnosis in Radiology: Educational CT CME Case Conference for Peer Review and Interpretative Improvement Pamela T. Johnson, David Badger, Karen M. Horton, Elliot K. Fishman http://dx.doi.org/10.1016/j.jacr.2016.05.015 - “The appeal is the ability to learn from challenging cases in an atmosphere that does not result in direct criticism of any individual physician. As a result, our search patterns, protocol design, and interpretative practice have been refined to avoid commonly missed diagnoses and misdiagnoses.”
Mitigating Misdiagnosis in Radiology: Educational CT CME Case Conference for Peer Review and Interpretative Improvement Pamela T. Johnson, David Badger, Karen M. Horton, Elliot K. Fishman http://dx.doi.org/10.1016/j.jacr.2016.05.015 - “The appeal is the ability to learn from challenging cases in an atmosphere that does not result in direct criticism of any individual physician. As a result, our search patterns, protocol design, and interpretative practice have been refined to avoid commonly missed diagnoses and misdiagnoses.”
Mitigating Misdiagnosis in Radiology: Educational CT CME Case Conference for Peer Review and Interpretative Improvement Pamela T. Johnson, David Badger, Karen M. Horton, Elliot K. Fishman http://dx.doi.org/10.1016/j.jacr.2016.05.015 - “A monthly CME conference with pa- thology and/or surgical correlation
and clinical follow-up is an excellent means of providing meaningful peer review to improve practice of the entire division and reduce interpretative errors.”
Mitigating Misdiagnosis in Radiology: Educational CT CME Case Conference for Peer Review and Interpretative Improvement Pamela T. Johnson, David Badger, Karen M. Horton, Elliot K. Fishman http://dx.doi.org/10.1016/j.jacr.2016.05.015
- " Human error is inevitable. "
Medical error-the third leading cause of death in the US.
Makary MA, Daniel M
BMJ. 2016 May 3;353:i2139. 
- "We calculated a mean rate of death from medical error of 251 454 a year using the studies reported since the 1999 IOM report and extrapolating to the total number of US hospital admissions in 2013. We believe this understates the true incidence of death due to medical error because the studies cited rely on errors extractable in documented health records and include only inpatient deaths. Although the assumptions made in extrapolating study data to the broader US population may limit the accuracy of our figure, the absence of national data highlights the need for systematic measurement of the problem. Comparing our estimate to CDC rankings suggests that medical error is the third most common cause of death in the US."
Medical error-the third leading cause of death in the US.
Makary MA, Daniel M
BMJ. 2016 May 3;353:i2139. - "Comparing our estimate to CDC rankings suggests that medical error is the third most common cause of death in the US."
Medical error-the third leading cause of death in the US.
Makary MA, Daniel M
BMJ. 2016 May 3;353:i2139. - "Human error is inevitable. Although we cannot eliminate human error, we can better measure the problem to design safer systems mitigating its frequency, visibility, and consequences. Strategies to reduce death from medical care should include three steps: making errors more visible when they occur so their effects can be intercepted; having remedies at hand to rescue patients; and making errors less frequent by following principles that take human limitations into account."
Medical error-the third leading cause of death in the US.
Makary MA, Daniel M
BMJ. 2016 May 3;353:i2139. - "Medical error has been defined as an unintended act (either of omission or commission) or one that does not achieve its intended outcome, the failure of a planned action to be completed as intended (an error of execution), the use of a wrong plan to achieve an aim (an error of planning), or a deviation from the process of care that may or may not cause harm to the patient."
Medical error-the third leading cause of death in the US.
Makary MA, Daniel M
BMJ. 2016 May 3;353:i2139. - "Currently, deaths caused by errors are unmeasured and discussions about prevention occur in limited and confidential forums, such as a hospital's internal root cause analysis committee or a department's morbidity and mortality conference. These forums review only a fraction of detected adverse events and the lessons learnt are not disseminated beyond the institution or department."
Medical error-the third leading cause of death in the US.
Makary MA, Daniel M
BMJ. 2016 May 3;353:i2139. - Summary points
● Death certificates in the US, used to compile national statistics, have no facility for acknowledging medical error
● If medical error was a disease, it would rank as the third leading cause of death in the US
● The system for measuring national vital statistics should be revised to facilitate better understanding of deaths due to medical care
- • A conservative estimate found that 5 percent of U.S. adults who seek outpatient care each year experience a diagnostic error.
• Postmortem examination research spanning decades has shown that diagnostic errors contribute to approximately 10 percent of patient deaths.
• Medical record reviews suggest that diagnostic errors account for 6 to 17 percent of hospital adverse events.
• Diagnostic errors are the leading type of paid medical malpractice claims, are almost twice as likely to have resulted in the patient’s death compared to other claims, and represent the highest proportion of total payments.
Improving Diagnosis in Healthcare
Committee on Diagnostic Error in Health Care Erin P. Balogh, Bryan T. Miller, and John R. Ball, Editors
Board on Health Care Services, Institute of Medicine
The National Academies Press, [2015] - • A conservative estimate found that 5 percent of U.S. adults who seek outpatient care each year experience a diagnostic error.
• Postmortem examination research spanning decades has shown that diagnostic errors contribute to approximately 10 percent of patient deaths.
• Medical record reviews suggest that diagnostic errors account for 6 to 17 percent of hospital adverse events.
• Diagnostic errors are the leading type of paid medical malpractice claims, are almost twice as likely to have resulted in the patient’s death compared to other claims, and represent the highest proportion of total payments.
Improving Diagnosis in Healthcare Committee on Diagnostic Error in Health Care Erin P. Balogh, Bryan T. Miller, and John R. Ball, Editors Board on Health Care Services, Institute of Medicine The National Academies Press, [2015] - “In reviewing the evidence, the committee concluded that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences. Despite the pervasiveness of diagnostic errors and the risk for serious patient harm, diagnostic errors have been largely unappreciated within the quality and patient safety movements in health care. Without a dedicated focus on improving diagnosis, these errors will likely worsen as the delivery of health care and the diagnostic process continue to increase in complexity.”
Improving Diagnosis in Healthcare Committee on Diagnostic Error in Health Care Erin P. Balogh, Bryan T. Miller, and John R. Ball, Editors Board on Health Care Services, Institute of Medicine The National Academies Press, [2015] - Goals for Improving Diagnosis and Reducing Diagnostic Error
• Facilitate more effective teamwork in the diagnostic process among health care professionals, patients, and their families
• Enhance health care professional education and training in the diagnostic process
• Ensure that health information technologies support patients and health care professionals in the diagnostic process
• Develop and deploy approaches to identify, learn from, and reduce diagnostic errors and near misses in clinical practice
• Establish a work system and culture that supports the diagnostic process and improvements in diagnostic performance
• Develop a reporting environment and medical liability system that facilitates improved diagnosis by learning from diagnostic errors and near misses
• Design a payment and care delivery environment that supports the diagnostic process
• Provide dedicated funding for research on the diagnostic process and diag- nostic errors - Goal 1: Facilitate more effective teamwork in the diagnostic process among health care professionals, patients, and their families
• Recommendation 1a: In recognition that the diagnostic process is a dynamic team-based activity, health care organizations should ensure that health care professionals have the appropriate knowledge, skills, resources, and support to engage in teamwork in the diagnostic process. To accomplish this, they should facilitate and support:
• Intra- and interprofessional teamwork in the diagnostic process.
• Collaboration among pathologists, radiologists, other diagnosticians, and treating health care professionals to improve diagnostic testing processes. - “Perceptual or cognitive errors made by radiologists are a source of diagnostic error. In addition, incomplete or incorrect patient information, as well as insufficient sharing of patient information, may lead to the use of an inadequate imaging protocol, an incorrect interpretation of imaging results, or the selection of an inappropriate imaging test by a referring clinician. Referring clinicians often struggle with selecting the appropriate imaging test, in part because of the large number of available imaging options and gaps in the teaching of radiology in medical schools.”
Improving Diagnosis in Healthcare Committee on Diagnostic Error in Health Care Erin P. Balogh, Bryan T. Miller, and John R. Ball, Editors Board on Health Care Services, Institute of Medicine The National Academies Press, [2015] - “Although consensus-based guidelines (e.g., the various “appropriateness criteria” published by the American College of Radiology [ACR]) are available to help select imaging tests for many conditions, these guidelines are often not followed. The use of clinical decision support systems at the point of care as well as direct consultations with radiologists have been proposed by the ACR as methods for improving imaging test selection.”
Improving Diagnosis in Healthcare Committee on Diagnostic Error in Health Care Erin P. Balogh, Bryan T. Miller, and John R. Ball, Editors Board on Health Care Services, Institute of Medicine The National Academies Press, [2015] - “Opportunities for improvement Medical imaging plays a key role in many diagnoses, and errors in the use and interpretation of these studies can contribute to diagnostic error. For the purposes of estimating the incidence of diagnostic error due to errors related to medical imaging, it would be useful to identify the subset of diagnoses for which medical imaging results are central to making the diagnosis and to conduct studies to determine the likelihood of errors, the nature of those errors, and the variation in the circumstances under which errors occur.”
Improving Diagnosis in Healthcare Committee on Diagnostic Error in Health Care Erin P. Balogh, Bryan T. Miller, and John R. Ball, Editors Board on Health Care Services, Institute of Medicine The National Academies Press, [2015] 
- “Communication errors are well recognized in the radiology literature and have been identified by The Joint Commission as the number one root cause in 65% of sentinel events that occur in hospitals; such errors have contributed to an estimated 44,000– 98,000 medical error–related deaths annually in the United States.”
Impact of Communication Errors in Radiology on Patient Care, Customer Satisfaction, and Work-Flow Efficiency Bettina Siewert et al. AJR 2016; 206:573–579 - “Several authors have confirmed this observation, reporting that communication errors contribute to 52% of severe incidents in hospitals and up to 80% in cases with multiple errors, where the string of mistakes is initiated by an error in informational or personal communication.”
Impact of Communication Errors in Radiology on Patient Care, Customer Satisfaction, and Work-Flow Efficiency Bettina Siewert et al. AJR 2016; 206:573–579 - “However, communication errors in radiology can occur at any step during the imaging process, from electronic ordering of a study by administrative office staff, to scheduling the examination, performing and interpreting the study, and having the written report or telephone communication conveyed to the referring clinician.”
Impact of Communication Errors in Radiology on Patient Care, Customer Satisfaction, and Work-Flow Efficiency Bettina Siewert et al. AJR 2016; 206:573–579 - “Surprisingly, our study showed that the majority of communication errors in radiology (52.6%) occurred at steps other than result communication—namely, during ordering, scheduling, performance, and interpretation of a study.” Impact of Communication Errors in Radiology on Patient Care, Customer Satisfaction, and Work-Flow Efficiency Bettina Siewert et al. AJR 2016; 206:573–579
- “The purpose of the study was to determine if increasing radiologist reading speed results in more misses and interpretation errors.”
The Effect of Faster Reporting Speed for Imaging Studies on the Number of Misses and Interpretation Errors: A Pilot Study. Sokolovskaya E et al. J Am Coll Radiol. 2015 Jul;12(7):683-8. doi: 10.1016/j.jacr. - “Reading at the faster speed resulted in more major misses for 4 of the 5 radiologists. The total number of major misses for the 5 radiologists, when they reported at the faster speed, was 16 of 60 reported cases, versus 6 of 60 reported cases at normal speed; P = .032. The average interpretation error rate of major misses among the 5 radiologists reporting at the faster speed was 26.6%, compared with 10% at normal speed.”
The Effect of Faster Reporting Speed for Imaging Studies on the Number of Misses and Interpretation Errors: A Pilot Study. Sokolovskaya E et al. J Am Coll Radiol. 2015 Jul;12(7):683-8. doi: 10.1016/j.jacr. - “Our pilot study found a significant positive correlation between faster reading speed and the number of major misses and interpretation errors.”
The Effect of Faster Reporting Speed for Imaging Studies on the Number of Misses and Interpretation Errors: A Pilot Study. Sokolovskaya E et al. J Am Coll Radiol. 2015 Jul;12(7):683-8. doi: 10.1016/j.jacr. - “To determine how physicians’ diagnoses, diagnostic uncertainty, and management decisions are affected by the results of computed tomography (CT) in emergency department settings.”
CT in the Emergency Department: A Real-Time Study of Changes in Physician Decision Making Pandharipande PV et al. Radiology 2016; 000:1–10 (in press) - “Both surveys were completed for 1280 patients by 245 physicians. The leading diagnosis changed in 235 of 460 patients with abdominal pain (51%), 163 of 387 with chest pain and/ or dyspnea (42%), and 103 of 433 with headache (24%). Pre-CT diagnostic confidence was inversely associated with the likelihood of a diagnostic change (P , .0001). Median changes in confidence were substantial (increases of 25%, 20%, and 13%, respectively, for patients with abdominal pain, chest pain and/or dyspnea, and headache; P , .0001); median post-CT confidence was high (95% for all three groups).”
CT in the Emergency Department: A Real-Time Study of Changes in Physician Decision Making Pandharipande PV et al. Radiology 2016; 000:1–10 (in press) - “Physicians’ diagnoses and admission decisions changed frequently after CT, and diagnostic uncertainty was alleviated.”
CT in the Emergency Department: A Real-Time Study of Changes in Physician Decision Making Pandharipande PV et al. Radiology 2016; 000:1–10 (in press) - “In this prospective, multicenter study, we found that, for common referral indications for CT in the emergency department (ie, abdominal pain, chest pain and/or dyspnea, and headache), physicians frequently changed their leading diagnosis (51%, 42%, and 24% of patients with abdominal pain, chest pain and/or dyspnea, and headache, respectively), diagnostic confidence (median increase of 25%, 20%, 13%), and admission decisions (25%, 19%, and 19% of patients with abdominal pain, chest pain and/or dyspnea, and headache, respectively) after CT results were available.”
CT in the Emergency Department: A Real-Time Study of Changes in Physician Decision Making Pandharipande PV et al. Radiology 2016; 000:1–10 (in press) - “Across all indications, we found that physicians’ diagnostic confidence before CT was inversely related to the likelihood of a change in leading diagnosis after CT (P , .0001), supporting the use of diagnostic confidence as a measure of diagnostic uncertainty; moreover, after CT, median diagnostic confidence levels were uniformly high (95% for all three patient groups), indicating that uncertainty was alleviated.”
CT in the Emergency Department: A Real-Time Study of Changes in Physician Decision Making Pandharipande PV et al. Radiology 2016; 000:1–10 (in press) - “For common referral indications to CT in emergency department settings, physicians’ diagnoses and admission decisions change frequently after CT and diagnostic uncertainty is alleviated; these findings suggest that current ordering practices are clinically justified.”
CT in the Emergency Department: A Real-Time Study of Changes in Physician Decision Making Pandharipande PV et al. Radiology 2016; 000:1–10 (in press) 
- What are the typical missed diagnosis seen in MDPC?
Poor study technique
Poor study interpretation
Poor understanding of typical appearances of Pancreatic masses
- “Errors in radiology reports may result from inappropriate terminology, transcription mistakes, or deficient or inadequately documented communication. Critical findings that may have an immediate impact on patient management must be promptly communicated to the referring physician and such communication fully documented. A meticulous and well-written report is the best way for radiologists to care for their patients. In addition, a well-worded report can be the deciding factor in a successful defense against a malpractice claim. Understanding the legal implications of radiology reports will enable radiologists to develop strategies for avoiding malpractice suits.”
The Malpractice Liability of Radiology Reports: Minimizing the Risk
Srinivasa Babu A, Brooks ML.
Radiographics. 2015 Mar-Apr;35(2):547-554 - “Oftentimes, a phrase regarding the suboptimal nature of a study is included in the radiology report, without alluding to the extent to which this renders adequate interpretation impossible. It is important not only to mention the reason why the study is inadequate, but also to suggest how to rectify the problem if the limitation hampers meaningful interpretation. For example, it is not sufficient to state that evaluation for pulmonary embolism is suboptimal due to poor contrast opacification secondary to bolus timing and motion artifact. A recommendation for a repeat study (with improved bolus timing and possible sedation to avoid motion artifact) within a definite time frame must be made. However, if the limitation of the study does not involve the region of interest, it may be sufficient to simply mention the limitation and reason without recommending follow-up (eg, if the upper abdomen is obscured by artifact at chest CT performed to rule out pulmonary embolism).”
The Malpractice Liability of Radiology Reports: Minimizing the Risk
Srinivasa Babu A, Brooks ML.
Radiographics. 2015 Mar-Apr;35(2):547-554 - “Structured reports created with standardized templates are gaining popularity, especially among trainees. Advantages of structured reports include (a) uniformity and improved communication with referring providers, (b) improved data mining and peer review process, (c) lesser likelihood of pertinent information being omitted by the radiologist, and (d) facilitation of the drawing of attention to critical findings. Disadvantages include (a) potential decrease in productivity due to radiologists’ not keeping their eyes on the images while assessing templates (the so-called eye dwell problem), (b) possible unsuitability of a report for complicated cases or cases in which a single disease entity affects multiple organs, and (c) possible lengthening of a report in a “normal” case.”
The Malpractice Liability of Radiology Reports: Minimizing the Risk
Srinivasa Babu A, Brooks ML.
Radiographics. 2015 Mar-Apr;35(2):547-554 - “Structured reports created with standardized templates are gaining popularity, especially among trainees. Advantages of structured reports include (a) uniformity and improved communication with referring providers, (b) improved data mining and peer review process, (c) lesser likelihood of pertinent information being omitted by the radiologist, and (d) facilitation of the drawing of attention to critical findings.”
The Malpractice Liability of Radiology Reports: Minimizing the Risk
Srinivasa Babu A, Brooks ML.
Radiographics. 2015 Mar-Apr;35(2):547-554 - “Disadvantages include (a) potential decrease in productivity due to radiologists’ not keeping their eyes on the images while assessing templates (the so-called eye dwell problem), (b) possible unsuitability of a report for complicated cases or cases in which a single disease entity affects multiple organs, and (c) possible lengthening of a report in a “normal” case.”
The Malpractice Liability of Radiology Reports: Minimizing the Risk
Srinivasa Babu A, Brooks ML.
Radiographics. 2015 Mar-Apr;35(2):547-554 - “A meticulous and well-written report is the best way for radiologists to care for their patients. Furthermore, a well-worded report can be the deciding factor in a successful defense against a malpractice action. Even if a radiologist identifies all the findings and makes a brilliant diagnosis, deficient reporting and communication of the information can result in a medicolegal debacle. In today’s contentious society, there is no escaping the practice of defensive medicine.”
The Malpractice Liability of Radiology Reports: Minimizing the Risk
Srinivasa Babu A, Brooks ML.
Radiographics. 2015 Mar-Apr;35(2):547-554 - “Checklists represent a form of task analysis in which the obvious is often incorporated with the not so obvious to ensure that steps are not forgotten. Thus, checklists initially were an air safety procedure to ensure that a step was not omitted and that standardized guidelines were followed. Therefore, checklists can exist to standardize actions, incorporate guidelines, and avoid omission of a key point. Checklists are also useful for self-checking of performance, self-assessment, and self-evaluation. What better way to organize the approach to a problem and to support success than to have the necessary steps readily available to the learner.”
Using a Checklist to Avoid Simple Errors of Omission
Wood BP
Acad Radiol , Volume 22 , Issue 3 , 267 - 268 - “There are several inherent problems with guidelines. One is that in the rush of excitement, as in an emergency situation, the checklist may not be available or may not pertain to the situation at hand. Because checklists are a weak replacement for common sense, they do not belong in every situation. If dependence on a checklist is strong, it may actually hinder performance in a time-critical situation. This is often the case in a medical emergency, unless there is someone present who has been especially trained in an essential procedure. This situation supports simulation training of key medical personnel to respond to an emergency situation.”
Using a Checklist to Avoid Simple Errors of Omission
Wood BP
Acad Radiol , Volume 22 , Issue 3 , 267 - 268
- Missed Diagnosis on CT: Causes
- Lesion is subtle and difficult to visualize especially when not part of the clinical request. Examples might include;
- Pulmonary embolism on an abdominal CT
- Site of GI bleed when the finding are subtle
- Neuroendocrine tumor in the pancreas (especially when under 1 cm)
- Small bowel tumor without obstruction or change in bowel caliber - Missed Diagnosis on CT: Dual Phase Imaging-2 Chances at Lesion Detection
- Lesions may be seen only on one of the phases (arterial or venous)
- Site of GI bleed
- Renal Cell Carcinoma as well as sites of metastases from renal cell carcinoma
- Neuroendocrine tumor in the pancreas (especially when under 3 cm)
- Small bowel tumor without obstruction or change in bowel caliber
- “ The skin and SQ tissues are by definition on the periphery of CT images and may often be overlooked by the interpreting radiologist. These findings may also be only partially included in the field of view, further complicating identification and interpretation.”
CT of the skin and subcutaneous tissues
Katz DS et al.
Emerg Radiol (2013):20;57-68 - Skin and Soft Tissue Pathology: CT Findings
- Trauma (laceration, bleed)
- Infection (abscess)
- Foreign body (silicon injections)
- Hematoma
- Calcifications
- Soft tissue tumors (melanoma, lymphoma) - “ Delayed diagnosis were not recognized on subsequent radiologic examinations in about one third of the cases. The most common types of error were underreading, satisfaction of search, faulty reasoning, and location of the finding.”
Fool Me Twice: Delayed Diagnoses in Radiology With Emphasis on Perpetuated Errors
Kim YW, Mansfield LT
AJR 2014;202:465-470 - “ In the daily radiology practice, the rate of interpretation error is between 3% and 4%; however, of the radiology studies that contain abnormalities, the error rate is even higher, averaging in the 30% range.”
Fool Me Twice: Delayed Diagnoses in Radiology With Emphasis on Perpetuated Errors
Kim YW, Mansfield LT
AJR 2014;202:465-470 - “ In our study, the majority of errors made were errors of underreading (42%), where the finding was simply missed. We advocate the use of checklists for different types of radiologic examinations, depending on the body part imaged, to facilitate active search patterns to decrease the incidence of this type of error.”
Fool Me Twice: Delayed Diagnoses in Radiology With Emphasis on Perpetuated Errors
Kim YW, Mansfield LT
AJR 2014;202:465-470 - “We advocate the use of checklists for different types of radiologic examinations, depending on the body part imaged, to facilitate active search patterns to decrease the incidence of this type of error.”
Fool Me Twice: Delayed Diagnoses in Radiology With Emphasis on Perpetuated Errors
Kim YW, Mansfield LT
AJR 2014;202:465-470 
Fool Me Twice: Delayed Diagnoses in Radiology With Emphasis on Perpetuated Errors
Kim YW, Mansfield LT
AJR 2014;202:465-470- “ This study shows that missed PE can occur on abdominal CT. It is recommended that interpretation include a careful search of the lower pulmonary arterial vasculature on contrast-enhanced abdominal CT scans.”
Missed Pulmonary Embolism on Abdominal CT
Lim KY, Kligerman SJ, Lin CT, White CS
AJR 2014; 202:738-743 - “ The challenge in identifying PE is clearly greater on abdominal CT than on chest CT. In addition to the multiple pitfalls described already, the lungs are typically not a primary target of abdominal CT interpretation, and only a limited part of the pulmonary anatomy is included.”
Missed Pulmonary Embolism on Abdominal CT
Lim KY, Kligerman SJ, Lin CT, White CS
AJR 2014; 202:738-743
- “ The majority of errors are false-negative interpretations and occur during interpretation of CT examinations. Recurring false-negative CT errors include failure to appreciate unexpected bowel or pancreatic malignancy, incidental pulmonary emboli, abnormality of vascular structures, bone lesions, omental disease, incidental abnormality present on targeted examinations on the periphery of the field of view.”
Eight CT lessons that we learned the hard way: an analysis of current patterns of radiological error and discrepancy with particular emphasis on CT
McCreadie G, Oliver TB
Clinical Radiology (2009) 64, 491-499 - Common False Negative Errors During CT Reporting
- Gastrointestinal tract tumor missed
- Pancreatic tumor missed
- Pulmonary embolus missed
- Vascular lesion missed
- Significant bone lesion missed
- Omental metastatic disease missed
- Incidental abnormality missed on targeted exam
- Lesion missed on periphery of the field of view
- Eight CT lessons that we learned the hard way: an analysis of current patterns of radiological error and discrepancy with particular emphasis on CT
McCreadie G, Oliver TB
Clinical Radiology (2009) 64, 491-499 - “ This idea (double reading of radiological examinations) is worthy of mention, but in reality the workload issues faced by most radiology departments make it impossible to resource significant double reporting activity.”
Eight CT lessons that we learned the hard way: an analysis of current patterns of radiological error and discrepancy with particular emphasis on CT
McCreadie G, Oliver TB
Clinical Radiology (2009) 64, 491-499
- “ Diagnostic errors are under recognized and underappreciated in radiology practice because of the inability to obtain reliable national estimates of the impact, difficulty in evaluating effectiveness of potential interventions, and poor response to systemwide solutions.”
Cognitive and System Factors Contributing to Diagnostic Errors in Radiology
Lee CS et al.
AJR 2013; 201:611-617 - “ Peer review is continuous, systematic, and critical reflection and evaluation of physician performance using structured procedures. Peer review acts as an essential tool to assess radiologists’ performance and to improve diagnostic accuracy.”
Cognitive and System Factors Contributing to Diagnostic Errors in Radiology
Lee CS et al.
AJR 2013; 201:611-617 - “ CT use constitues the majority of medical radiation exposure. Cancer induction by medical radiation at low doses is controversial, with the most widely accepted estimates being outlined in the 2006 BIER VII report. Radiologists should be prepared to answer questions related to radiation dose and cancer risks associated with CT.”
CT Radiation Dose: Current Controversies and Dose Reduction Strategies
Costello JE et al.
AJR 2013; 201:1283-1290 - “Radiologists should be prepared to answer questions related to radiation dose and cancer risks associated with CT.”
CT Radiation Dose: Current Controversies and Dose Reduction Strategies
Costello JE et al.
AJR 2013; 201:1283-1290
- “Errors in diagnosis are, by far, the most common genetic cause of malpractice suits against radiologists. In this category, breast cancer was the most frequently missed diagnosis, followed by nonvertebral fractures and spinal fractures. Failure to communicate, and failure to recommend additional testing are both uncommon reasons for initiating a suit.”
The Causes of Medical Malpractice Suits Against Radiologists in the United States
Whang JS et al.
Radiology 2013; 266:548-554 - “Our data then indicate that interpretive errors, rather than communication errors, are by far the most generic cause of malpractice suits against radiologists.”
The Causes of Medical Malpractice Suits Against Radiologists in the United States
Whang JS et al.
Radiology 2013; 266:548-554 - What are the most common organ systems involved-
- Breast
- Nonspinal musculoskeletal
- Spinal musculoskeletal
- Pulmonary
- Gastrointestinal - - The Causes of Medical Malpractice Suits Against Radiologists in the United States
Whang JS et al.
Radiology 2013; 266:548-554