More knowledge sharing helps to eliminate errors

August 18, 2005

Reporting discrepancies are common in radiology, but very few of them affect patient management. They can occur due to problems of technique, perception, knowledge, and judgment, and, often, a combination of these factors. In many cases, the causes are not just individual but systemic.

Reporting discrepancies are common in radiology, but very few of them affect patient management. They can occur due to problems of technique, perception, knowledge, and judgment, and, often, a combination of these factors. In many cases, the causes are not just individual but systemic.

A discrepancy may occur between retrospective review of an image (or an outcome in a patient) and the original report, but not all discrepancies are due to radiological errors. Radiology reports are just part of a jigsaw puzzle, and the patient's clinical information available to the reporting radiologist may be inadequate, incomplete, or incorrect. Even if a radiology report has the potential to adversely affect patient management, often it does not. Clinicians do not rely solely on radiologists to provide an imaging tissue signature. They also consider a patient's history, physical examination, and any other investigations.

It is difficult to keep up to date with the latest technologies, implementation of PACS, etc., so ongoing training issues must be addressed. A few hours of targeted instruction can make a big difference. Web sites, such as www. CTisus.com and www.radiology education.com, can also help to improve technique.

Not all staff members have to be able to undertake complex tasks on a new scanner. The greatest benefit to patients is not derived from a minority performing at the highest level, but from everyone performing at an adequate level appropriate to their patient case mix.

Traditionally, perception has been viewed as the cause of error in radiology, false negatives being more numerous than false positives. That might be the case in some areas, such as emergency radiology reporting, but in general it does not account for most errors. Problems of technique and interpretation are also important causes.

Perception can be compromised by excess workload, constant interruptions, lack of sleep, a poor reporting environment, a toxic atmosphere in a department, inadequate clinical information, lack of previous imaging, and the absence of double reading or computer-aided diagnosis. Eye strain is another common problem, especially for those doing more than six hours of reporting in a day. Radiologists can learn a lot from air-traffic controllers. In the U.K., they have a 32-hour working week, take a 30-minute break every 90 minutes, and work in pairs and double-report.

The wording of a radiological re-port must be unambiguous, so that clinicians will appreciate its full meaning. We must "maximize signal" and "minimize noise." In this respect, local radiologists have an advantage over those working remotely because they are familiar with the clinical setting and know the local clinicians.

More openness about the incidence of radiological error, as well as departmental practice of peer support instead of blame, could help radiologists learn from mistakes and improve their performance. More knowledge sharing about pitfalls in imaging is required. We need to honestly review the less satisfactory sides of our practice and publish them.

Radiologists have a team role as well as a technical role. By virtue of our individual personalities, each of us has particular strengths and weaknesses. We need to analyze which type of role we are best suited to. We should be more understanding about the various personality traits of colleagues.

We must not encourage complacency, accept poor standards, or cover up unacceptable practice. Individual accountability always remains, wheth-er or not there is a systems culture. We should learn from past errors and feel more secure about discussing discrepancies. This will improve not only patient care but also our own working lives. We need to place a higher value on fixing the system rather than punishing individuals.

There is no magic wand that will eliminate error in radiology. A quantum improvement in diagnostic performance is possible through teamworking. Targeted, supportive advice and instruction on an informal daily basis is most important in improving accuracy. Everyone must feel confident that they can ask for help without fear of derision or repercussions.

DR. FITZGERALD is a radiologist at the Royal Wolverhampton Hospitals NHS Trust, U.K. He is a member of the Royal College of Radiologists' Standards Subcommittee and a General Medical Council radiologist assessor.