E1610. Evaluating and Responding to Mistakes on Radiology Reports
  1. Mirza Baig; Westchester Medical Center
  2. Sheldon Lerman; Westchester Medical Center
  3. Nicholas Mui; New York Medical College
  4. Ek Gofur; Westchester Medical Center
  5. Mayer Rubin; Westchester Medical Center
  6. Perry Gerard; Westchester Medical Center
  7. Jared Meshekow; Temple University, Lewis Katz School of Medicine
Errors and discrepancies in radiology reporting from incorrect, missed, or delayed diagnoses can, directly or indirectly, result in devastating consequences for a patient. Errors can be categorized into four main subsets: technique or image acquisition, perception, cognitive/interpretation, and communication. Just as important as recognizing errors is the communication of these mistakes to clinicians, so that the patient may be updated, and the information can be relayed to the treatment team to determine the next step in care.

Educational Goals / Teaching Points
Describe the common types of radiological errors. Discuss ways to streamline communication between radiologists and referring physicians and handle difficult patient or provider communication.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Technique or image acquisition errors are caused by the limitations of the modality. This includes artifacts that may obscure pathology or mimic a positive finding. Errors in perception occur when no abnormality is identified and results in under-reading, which may be caused by a misleading history, and/or satisfaction of search. Cognitive/interpretative errors are attributed to when a variant is visualized but incorrectly understood, leading to an intended diagnosis. Lastly, communication errors occur from failure to effectively communicate the results of important findings or in making proper recommendations. Communication errors have been recognized to be a leading cause in sentinel events according to the Joint Commission. As most of these communication errors occur during hand-offs of patient care, radiology reports can be equated to a written “hand-off” from the radiologist to the referring clinician. Subpar communication with the ordering provider and/or treatment team may result in deleterious physical and/or mental consequences for a patient. Certain strategies to minimize radiology reporting errors include but are not limited to adopting standardized imaging protocols, optimizing the work environment by avoiding interruptions/distractions, reducing the workload and fatigue, implementing a systematic search and checklist, and adopting rigorous communication protocols and policies. Once a mistake is discovered, is also imperative to be proactive and acknowledge the mistake to the referring physician, allowing them to regain trust and make amends.

Radiology reporting errors are ubiquitous and nearly unavoidable in radiology and medicine, with some studies reporting errors ranging from an estimated 5 - 20%. However, with increased awareness of the factors leading to these errors and knowledge of strategies to reduce mistakes, radiologists can mitigate potential adverse ramifications.