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3D and Workflow: Medical Error Imaging Pearls - Learning Modules | CT Scanning | CT Imaging | CT Scan Protocols - CTisus
Imaging Pearls ❯ 3D and Workflow ❯ Medical Error

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  • “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
© 1999-2017 Elliot K. Fishman, MD, FACR. All rights reserved.