Twenty years ago, the Institute of Medicine published its seminal report, To Err Is Human, examining the number of medical errors that occur annually in the United States and the root causes behind them.
Two decades later, all of healthcare—including radiology—is still wrestling with this problem and how to minimize it.
“Even with the tremendous advancements in radiology science, an increased understanding of what disease looks like, and greater education of radiology knowledge, we still have a persistent error rate that’s at least 3%,” says Michael Bruno, MD, vice chair for quality and chief of emergency radiology at Penn State University. “It’s very stubborn and won’t go away.”
With mistakes still occurring in the industry, providers need to know how to address them and, potentially, minimize the risk that they’ll happen again in the future.
Why mistakes happen
Part of the difficulty in combatting errors, Bruno says, is that it’s impossible to stop them from occurring overall. Radiologists are human, and each one will eventually make a mistake. Reducing that 3% error rate is also hard because mistakes happen for a wide variety of reasons.
According to Richard Gunderman, MD, PhD, Chancellor’s Professor at Indiana University School of Medicine, fatigue from working too long or too intensely can cause radiologists to make mistakes, or they could be distracted by phone calls or frequent interruptions. In some cases, a radiologist could make errors because they’re asked to interpret and render a diagnosis on an abnormality that lies just outside their zone of expertise.
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Under these circumstances, radiologists can make several types of errors. While rare, Bruno says, errors of omission—a missed diagnosis—happen when providers simply don’t see an abnormality because it’s located in an unusual spot or it appears in only one image in the series.
Other mistakes, called “satisfaction of search” errors, occur when a provider overlooks one of two findings present in an image. Even though providers continue to analyze an image after identifying one finding he says, a second, whether obvious or inconspicuous, can be missed.
And, sometimes the fault lies with the organization’s systems and processes rather than with the individual radiologist. Faulty protocols can set a provider up for failure even under the best of circumstances.
What to do when errors occur
After identifying a mistake, whether it’s a diagnostic or reporting error, a provider’s first responsibility is ensuring the patient receives the appropriate care, says Stephen Brown, MD, associate professor of radiology at Boston Children’s Hospital and Harvard Medical School.
After that, he says, start communicating.