We All Make Mistakes

July 18, 2016

But what radiologists do with the mistakes is even more important.

It’s a well-known fact that we all make mistakes. Whether you are a lawyer, a doctor, a professional athlete or even a radiologist. It’s bound to happen, and anyone that tells you otherwise, isn’t worth the air that they breathe. What everyone tries to do is to be as careful as they can, doing whatever it is that they do for a living, and to give their best effort each and every time. Whether you are playing a basketball game, baking a cake, or reading a CT scan.

The problem arises when someone does make a mistake. Mistakes, as we all know, come in all sizes and flavors. And as we also know in radiology, mistakes happen every day. In fact, Renfrew et al. proposed a 12-tier classification system for errors in radiology!

There are the unforeseeable mistakes like the IV that blows in 88-year-old Mrs. Smith’s arm that causes intravenous contrast to infiltrate into her subcutaneous tissue during her CT. Sure, the CT tech was careful in starting the IV, and I’m sure he/she watched the site as a test bolus or saline flush seemed to flow nicely, before hooking the patient up to the power injector. But, for whatever reason, the IV infiltrated, and the patient suffered an unforeseeable, and thankfully usually self-limiting mistake.

Then there’s the mistake that the radiologist makes in his/her report. It could be the 2 mm renal cyst that they failed to detect. Technically, does this constitute a mistake? Sure, but does it have any clinical relevance? Unlikely.

Then there are the mistakes that really count. The 9 mm solitary pulmonary nodule that you missed at the left lung base on a CT of the abdomen and pelvis done for some completely different reason. Or the 12 mm enhancing renal lesion that needs further workup. How about the intra-articular elbow fracture on the 8-year-old boy that fell off his hover board?

We all try our best to avoid them, but we all make them. The hard part, in my opinion, comes when you recognize one of these “mistakes that count,” in one of your partner’s reports, or one of your associate’s reports from another department.[[{"type":"media","view_mode":"media_crop","fid":"50250","attributes":{"alt":"Mistake","class":"media-image media-image-right","id":"media_crop_2784181459833","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6122","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 200px; width: 200px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"©Pretty Vectors/Shutterstock.com","typeof":"foaf:Image"}}]]

How do you handle this? You never want to come off as arrogant or snotty by walking right up to the person and saying, “Hey Joe, you remember that MRI you read on Mrs. Jones? Well, you missed the comminuted fracture of the tibial plateau. I thought you might want to know about it.” If you do this, not only do you run the risk of your partner never speaking to you again, but it will likely anger them to the point where they will likely want to seek revenge, whereby they will scrutinize your reports in search of an error that they can call you on.

Then there are those mistakes where you think someone made an error, simply because of your instinct and experience, but you just don’t have definitive proof, and you’re not 100% sure, and you just don’t know where to turn. This happened to me just the other day. A 56-year-old woman presented with a routine chest X-ray demonstrating multiple nodules and masses. A CT was recommended, and was performed the next day. That study confirmed the presence of multiple pulmonary metastases but also, hepatic, renal, and osseous metastases. The patient clearly had very progressive stage IV disease from an unknown primary. A liver biopsy was then performed and the pathologist reported it out as a very unusual and rare type of cancer. Not what one would expect, given the history and imaging findings. Do you question the pathologist’s interpretation? Do you ask him/her to send the slides out for a second opinion? Truly an awkward situation, with no really good answer. Given the patient’s diffuse metastatic disease, and probably poor prognosis, does it really make a difference? Maybe not, but in a different situation, doesn’t it serve the patient’s best interests to question a diagnosis, if there is a doubt, and if it might change the patient’s management or outcome? Or, do you just chalk it up to, “we all make mistakes.”

Something to definitely think about…