Elliot K. Fishman M.D.
Johns Hopkins Hospital

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“ 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.”
Fool Me Twice: Delayed Diagnoses in Radiology With Emphasis on Perpetuated Errors
Kim YW, Mansfield LT
AJR 2014;202:465-470

“ 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

“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.

“Radiologists may not be aware of additional resources available at the scanner and the workstation to increase lesion conspicuity and detection as image quality and quantity decrease, including virtual noncontrast data sets from dual-energy CT, 3-D rendering (maximum intensity projection [MIP], volume rendering [VR], and cinematic rendering [CR]), computer-assisted diagnosis, and texture analysis.” 
Enhancing Image Quality in the Era of Radiation Dose Reduction: Postprocessing Techniques for Body CT
Pamela T. Johnson, Elliot K. Fishman 
J Am Coll Radiol. 2018 Mar;15:486-488

“The process of achieving value in terms of medical decision support does not remove the clinician or radiologist, but instead, provides easier access to information that might otherwise be inaccessible, inefficient, or difficult to integrate in real-time for the consulting physician. When this information is distilled in a way available to the radiologist, it becomes knowledge that can positively impact the clinician’s judgment in a personalized way in real-time.”
Reinventing Radiology: Big Data and the Future of Medical Imaging 
Morris MA et al.
J Thorac Imaging 2018;33:4–16

Results: Implementation of the checklist led to further actions in 25.9% of cases. The most common actions were calls to referring providers to modify or clarify an order (24.3%), followed by verification of proper pre- medication in patients with allergy to iodinated contrast (12.7%) and contacting the radiologist for protocolling (12.7%). 
Conclusions: Implementation of a pre-CT checklist that can be tailored to individual practices has potential to improve patients' safety and experience as well as providing a more efficient clinical operation.Summary sentence: We present an easy-to-implement checklist to maximize CT throughput in an outpatient setting that can be customized to the needs of individual institutions and has the potential to improve patients' safety and experience. 
The pre-CT checklist: A simple tool to improve workflow and patient safety T in an outpatient CT setting 
Sheila Sheth, Beatrice Mudge, Elliot K. Fishman
Clinical Imaging 66 (2020) 101–105

Summary sentence: We present an easy-to-implement checklist to maximize CT throughput in an outpatient setting that can be customized to the needs of individual institutions and has the potential to improve patients' safety and experience. 
The pre-CT checklist: A simple tool to improve workflow and patient safety T in an outpatient CT setting 
Sheila Sheth, Beatrice Mudge, Elliot K. Fishman
Clinical Imaging 66 (2020) 101–105

The pre-CT checklist: A simple tool to improve workflow and patient safety T in an outpatient CT setting 
Sheila Sheth, Beatrice Mudge, Elliot K. Fishman
Clinical Imaging 66 (2020) 101–105

“ The work-up of hematuria should be individualized and risk base. Given the a priori low likelihood of cancer in hematuria, risk categories should be established and imaging algorithms should be tailored to populations at low-risk, medium risk and high risk for developing urothelial cancer.”
Hematuria: A Problem-Based Imaging Algorithm Illustrating the Recent Dutch Guidelines on Hematuria
van der Molen AJ, Hovius MC
AJR 2012; 198:1256-1265

“In patients less than 35 years old, ostensibly at much lesser risk of developing renal malignancies, we acquire only noncontrast, arterial, and delayed phase images, because the odds of the patient having either a renal parenchymal lesion or a significant abnormality in the other parenchymal organs of the upper abdomen are much less, making venous phase acquisitions of less value.”
Upper and Lower Tract Urothelial Imaging Using Computed Tomography Urography
Raman SP, Fishman EKRadiol
Clin North Am 2017 Mar;55(2):225-241. 

“The routine use of contrast (both oral and IV, and certainly rectal) is unnecessary for the majority of abdominal CT scans performed in the ED.  At least that is what the literature says over and over. Unfortunately, many radiologists disagree.  Is their objection based on a sound analysis of the literature?  Hardly.  In most cases it is a matter of personal preference.  They have been using contrast since their residency, or at least since CTs came on the scene, and just feel more comfortable with it. Have they made an honest effort to compare results with and without contrast ?  Probably not.  Do they care that oral contrast will add about two hours to an ED stay and, even when given, frequently doesn’t get to the cecum?  Probably not.”

Oral contrast

• Water
• Omnipaque-350
• VoLumen

Intravenous contrast

• 100-120 cc of Omnipaque -350
• Injection rate of 3-5 cc/sec

“The historical basis for preparative fasting for contrast-enhanced CT is the concern over pulmonary aspiration of gastric contents and aspiration pneumonia after vomiting. Though this may have been a significant clinical issue for first-generation hyperosmolar contrast agents, which caused nausea and vomiting in 4.58% and 1.84% of cases, respectively, the introduction of nonionic low-osmolarity contrast agents has decreased the frequency of vomiting to approximately 0.3%.”
Preparative Fasting for Contrast- Enhanced CT in a Cancer Center: A New Approach 
Paula N. V. P. Barbosa et al.
AJR 2018; 210:941–947

“In the present investigation, patients also reported unexpected symptoms after contrast agent administration, such as flushing, dizziness, ear pruritus, tingling, tremor, pain at the injection site, tachycardia, and headaches. These manifestations, referred to as “other unexpected symptoms,” were significantly associated with fasting. Though infrequent, these symptoms are likely to contribute to patient irritability and uncooperativeness.”
Preparative Fasting for Contrast- Enhanced CT in a Cancer Center: A New Approach 
Paula N. V. P. Barbosa et al.
AJR 2018; 210:941–947

“Patients preferred dilute iohexol over dilute diatrizoate sodium for oral contrast for abdominal-pelvic CT. There was no significant difference in bowel opacification or adverse effect profile.”
Oral Contrast Media for Body CT: Comparison of Diatrizoate Sodium and Iohexol for Patient Acceptance and Bowel Opacification
McNamara MM et al.
AJR 2010;195:1137-11411

“Of 287 subjects who expressed a preference, 233 patients (81%) preferred dilute iohexol compared with 54 patients (19%) who preferred dilute diatrizoate sodium.ten patients had no preference and 3 did not complete the taste comparison study.”
Oral Contrast Media for Body CT: Comparison of Diatrizoate Sodium and Iohexol for Patient Acceptance and Bowel Opacification
McNamara MM et al.
AJR 2010;195:1137-11411