A new complication registration system for errors in radiology: Initial 5-year experience in a tertiary care radiology department

PURPOSE

To describe and evaluate our initial 5-year experience with a new complication registration system for errors in radiology.

MATERIALS AND METHODS

This study reviewed all cases that were submitted to a new complication registration system of a tertiary care radiology department between 2015-2019.

RESULTS

Sixty-seven cases were included. In the group of diagnostic complications/errors (n = 34), there were 21 perceptual errors and 13 cognitive errors. This 61.8 % (21/34) perceptual error rate was not significantly different (P = 0.297) from the 70 % perceptual error rate known from previous literature. In the group of interventional complications (n=19), most cases (47.4 % [9/19]) concerned symptomatic or major hemorrhage. In the group of organizational complications/errors (n=14), the leading incident type according to the International Classification System for Patient Safety was clinical process/procedure with wrong body part/side/site as subclassification (35.7 % [5/14]). Harm severities were none (n=35), mild (n=10), moderate (n=10), severe (n=6), death (n=5), and unknown (n=1). Harm severity of interventional complications was significantly higher (P < 0.05) than that of organizational complications, while there were no significant differences in harm severities between other groups of complications.

CONCLUSION

It is feasible to implement the radiologic complication registration system that was described in this study. Perceptual mistakes, hemorrhage, and procedures on the wrong body part/side/site dominated in the categories of diagnostic, interventional, and organizational complications/errors, respectively, and these should be the topic of vigilance in clinical practice and further research. Future studies are also required to determine whether this complication registration system reduces radiologic errors and improves healthcare quality.

Basal cell carcinoma misdiagnosed as trichoepithelioma

Trichoepithelioma is a benign hair follicle tumor that can undergo malignant transformation into basal cell carcinoma in rare cases. Due to the similar clinical and histological features of trichoepithelioma and basal cell carcinoma, distinguishing between these types of tumors can be a diagnostic challenge. Punch biopsy obtains only a small sample of the entire lesion, and thus inherently involves a risk of misdiagnosis between histologically similar diseases. Therefore, if the possibility of misdiagnosis can reasonably be suspected, clinicians should conduct an excisional biopsy or immunohistochemical staining (e.g., CD10 and Bcl-2) to ensure an exact diagnosis. Although trichoepithelioma is benign, the surgical excision of solitary trichoepithelioma should be considered in order to avoid the possibility of malignant transformation, which has occasionally been documented for multiple familial trichoepitheliomas. Herein, we report a case that was initially misdiagnosed as trichoepithelioma before ultimately being diagnosed as basal cell carcinoma through excision and immunohistochemical staining.

[Cell morphological analysis of hepatosplenic T-cell lymphoma gamma-delta type]

Objective: To analyze the cell morphological features of hepatosplenic T-cell lymphoma (HSTCL) gamma-delta (γδ) type, differentiate from acute leukaemia (AL). Methods: This was a retrospective study. The clinical data of four cases of HSTCL γδ type who were treated in Hebei Yanda Ludaopei Hospital from 2009 to 2014 were collected. Their initial morphology diagnoses in other hospitals were all acute leukemia or myelodysplastic syndrome (MDS). Morphological analysis and cytochemical stains to their bone marrow (BM) aspiration and peripheral blood (PB) smears were completed when they had no response to previous chemotherapies, and the morphological reports were compared with results of immunophenotyping, chromosome, and T cell receptor (TCR) gene rearrangement. Results: The percentages of malignant cells in four patients' BM aspirations were 7.6%-40.0%, and in two patients' PB was 9% and 10%, respectively. The morphology of four cases had a very high similarity in Wright's stain. Predominantly medium-sized cells were seen, with rich cytoplasm and frequently one big conspicuous nucleolus. The malignant cells resembled blasts, especially monoblasts, but with coarse granular chromatin, more compact than that in monoblasts. When comparing to malignant myeloblast and lymphoblasts, HSTCL cells were larger and more irregular in cell shape, with more abundant cytoplasm and prominent nuclear irregularity. The cytochemistric stain played an important role in differential diagnosis. HSTCL malignant cells showed non-specific esterase (NSE) negative or focal punctate activity which couldn't be inhibited by sodium fluoride. Periodic acid-Schiff (PAS) stain was negative or positive with a form of coarse granules. The myeloperioxdase (MPO) stain was negative. Conclusion: Malignant cells of HSTCL γδ type have very distinct morphological features of mature lymphocytic neoplasm. The quality of Wright's stain, being short of complete cytochemical stains, lacking of awareness of this disease, and acute leukemia or MDS like appearance in some cases, result in the possibility of diagnostic error as malignant blast, and probably are main causes of misdiagnosis of HSTCL γδ type.

The Importance of STAT6 in a Schwannoma-like Grade III Solitary Fibrous Tumor/Hemangiopericytoma Located in the Cerebellopontine Angle and Meckel's Cave

BACKGROUND

Hemangiopericytoma (HPC) is a rare mesenchymal tumor of the brain that occurs in the central nervous system as a solitary fibrous tumor. Surgical treatment of HPC is known to be beneficial, but results on the role of complete resection and adjuvant radiation are conflicting. However, it is often difficult to detect a central nervous system solitary fibrous tumor/HPC before surgery. We describe a presumed left trigeminal schwannoma that was histopathologically shown to be an HPC.

CASE DESCRIPTION

A 65-year-old man presented with paresthesia of the second and third branches of the left trigeminal nerve. Magnetic resonance imaging showed a tumoral lesion in the left cerebellopontine angle and Meckel's cave. We suspected a schwannoma and performed surgery, which resulted in only a partial resection because of tumor bleeding and unexpected intraoperative histologic findings. We could not achieve a definitive diagnosis. However, we observed local recurrence and disseminated lesions 5 and 6.5 years later, respectively. We performed a second surgery and were able to definitively diagnose the lesion as a grade III HPC based on the positive expression of STAT6 during immunostaining.

CONCLUSIONS

As solitary fibrous tumor/HPC requires gross total resection for effective resolution, it is imperative to consider it in the differential diagnoses of similar tumors. If an unusual pathologic image is found, we recommend rapid immunostaining for STAT6 to reach a definitive conclusion regarding the tumor type. This case highlights the importance of considering HPC when screening or diagnosing central nervous system lesions, especially in this rare location.

Medical disciplinary jurisprudence in alleged malpractice in radiology: 10-year Dutch experience

PURPOSE

To systematically investigate the frequency and types of allegations related to radiology practice handled by the Dutch Medical Disciplinary Court in the past 10 years.

METHODS

The Dutch Medical Disciplinary Court database was searched for verdicts concerning radiology practice between 2010 and 2019. The association between the number of verdicts and time (years) was assessed by Spearman's rho. Other data were summarized using descriptive statistics.

RESULTS

There were 48 verdicts (mean 4.8 per year). There was no significant association between the number of verdicts and time (Spearman's rho < 0.001, p = 0.99). Most allegations were in breast imaging and musculoskeletal radiology (each 18.8%), followed by interventional radiology, head and neck imaging, and abdominal imaging (each 12.5%), neuroradiology and vascular imaging (each 10.4%), and chest imaging (4.2%). There were 46 allegations against radiologists (95.8%) and 2 against residents (4.2%). The most common allegation (37.5%) was error in diagnosis. In 20.8% of verdicts, the allegation was judged (partially) founded; disciplinary measures were warnings (n = 8) and reprimands (n = 2). An appeal was submitted by the patient in 11 cases and by the radiologist in 3 cases. All appeals by patients were rejected, whereas 2 of the 3 appeals by radiologists were granted and previously imposed disciplinary measures were reversed.

CONCLUSION

Allegations against radiologists at the Dutch Medical Disciplinary Court are relatively few, their number has remained stable over the past 10 years, and a minority were judged to be (partially) founded. We can learn from the cases presented in this article, which may improve patient care.

KEY POINTS

• The frequency of allegations against radiologists at the Dutch Medical Disciplinary Court is relatively low and has not exhibited any temporal change over the past 10 years. • These allegations reflect patient dissatisfaction, but this infrequently equals malpractice. • Knowledge of the circumstances under which these allegations have arisen may improve patient care.

Pitfalls in the MDCT of pancreatic cancer: strategies for minimizing errors

Multidetector computed tomography (MDCT) is a widely used cross-sectional imaging modality for initial evaluation of patients with suspected pancreatic ductal adenocarcinoma (PDAC). However, diagnosis of PDAC can be challenging due to numerous pitfalls associated with image acquisition and interpretation, including technical factors, imaging features, and cognitive errors. Accurate diagnosis requires familiarity with these pitfalls, as these can be minimized using systematic strategies. Suboptimal acquisition protocols and other technical errors such as motion artifacts and incomplete anatomical coverage increase the risk of misdiagnosis. Interpretation of images can be challenging due to intrinsic tumor features (including small and isoenhancing masses, exophytic masses, subtle pancreatic duct irregularities, and diffuse tumor infiltration), presence of coexisting pathology (including chronic pancreatitis and intraductal papillary mucinous neoplasm), mimickers of PDAC (including focal fatty infiltration and focal pancreatitis), distracting findings, and satisfaction of search. Awareness of pitfalls associated with the diagnosis of PDAC along with the strategies to avoid them will help radiologists to minimize technical and interpretation errors. Cognizance and mitigation of these errors can lead to earlier PDAC diagnosis and ultimately improve patient prognosis.

[Chromophobe renal cell carcinoma-diagnosis and prognosis]

Chromophobe renal cell carcinoma is one of four malignant kidney tumor subtypes. Due to its morphological variance in clinical pathological routine diagnostics, this subtype can cause certain difficulties. The tumor can be mistaken for more aggressive or benign tumors. In both cases the consequences of misdiagnosis regarding treatment decisions can be serious. Due to the morphological variance of the tumor, it has not yet been possible to develop a generally accepted, prognostically convincing graduation scheme. The aim is to improve the quality of diagnostics and estimation of prognosis for this subtype of tumor in order to optimize patient care.

Clinical and Echocardiographic Characterization of False-Positive Results from Stress Echocardiography

BACKGROUND

Stress echocardiography has a 72%–85% sensitivity and an 80%–95% specificity. In this study, we characterized patients who received a false-positive stress echocardiogram result.

METHODS

A total of 5,256 patients underwent a stress echocardiogram (induced by exercise, dobutamine, or dipyridamole) between 2009 to 2018, and 405 patients (7.7%) received a positive result. Among the positive patients, 300 underwent coronary angiography within 12 months, and these patients were included in this study (mean age = 64.9 ± 9.4 years, 230 men [76.7%]). Coronary artery disease was diagnosed by stenosis ≥50% in any epicardial coronary artery. Clinical and echocardiographic variables were compared between patients with true- and false-positive stress echocardiogram results.

RESULTS

Seventy-two patients (24%) had a false-positive stress echocardiogram, with similar rates across stressor types (p = 0.574). Patients with false positives were less frequently men (63.9% vs. 80.7%, p = 0.003), had lower diabetes mellitus prevalence (15.3% vs. 45.6%, p = 0.001), were similar to true positive patients with regard to body-mass index, arterial hypertension prevalence, hyperlipidemia and smoking, and had lower pre-test probability of coronary artery disease (23% vs. 32%, p = 0.016). The wall motion score index (WMSI) was higher in the true-positive stress group, and wall motion abnormalities were more frequent in the apical segments (70.5% vs. 56.7%, p = 0.034). In a multivariable predictive model, men (odds ratio [OR] = 2.994), diabetes (OR = 5.440), and peak WMSI (OR = 10.690) were associated with a true-positive result.

CONCLUSIONS

Twenty-four percent of our study population received a false-positive stress echocardiogram result, with similar rates across stressor types. Patients with true-positive stress echocardiogram results are more likely to be men, diabetic, and have a high peak WMSI.

Does physician distraction lead to diagnostic and management errors? An exploratory study in the primary care setting

OBJECTIVES

There is an increasing concern about diagnostic errors and their impact on patient safety. Physicians' diagnostic ability is significantly undermined by certain distractions that can carry potential negative consequences such as diagnostic and management errors. This study aimed to examine the effects of distracting factors for physicians during consultation and their consequent effects on diagnostic accuracy and disease or condition management.

METHODS

Family medicine residents at a major training hospital in KSA were randomly assigned to two groups of simulated patients: one group with patients with distracting features and another group with patients without distracting features (the control group). Both groups encountered six simulated patients with different clinical conditions or diseases. The consultation time, accuracy of diagnosis, appropriateness of management, number of outlines of treatment, and simulated patient satisfaction were measured for both groups.

RESULTS

A total of 70 simulated physician-patient encounters were conducted with 35 residents. Consultation time was significantly longer for encounters with patients with distracting features, which had a mean time of 7.43 min, compared with encounters with non-distracting patients, which had a mean time of 4.4 min (p value < 0.0001). There were no significant statistical differences in accuracy of diagnosis, appropriateness of management, or patient satisfaction between the two groups. However, residents recommended a higher number of outlines of treatment for patients with distracting features (2.96 for distracting patients versus 2.46 for non-distracting patients; p < 0.011).

CONCLUSION

Distracting factors are associated with prolonged consultation time among physicians. Although this study did not demonstrate any effects of distracting factors on accuracy of diagnosis or disease management, these factors are still concerning, especially in complex clinical situations and situations where there is lack of reflective practice. The effects of distracting factors should be minimized to ensure patient safety.

First do no harm: overdiagnosis in Pediatrics

Many errors can be made in diagnosis: underdiagnosis, misdiagnosis, and overdiagnosis. While underdiagnosis and misdiagnosis are clear errors, in overdiagnosis, a true abnormality is discovered, but detection does not benefit the patient. Harm occurs when patients are further evaluated and treated unnecessarily as a result of making a diagnosis that would never have affected the patient if the diagnosis had not been made. Several phenomena point to potential overdiagnosis: when delayed or missed diagnoses do not result in harm; when there is increased detection of a disease, but no change in the outcome; and when randomized trials show no benefit from the diagnosis. Some might say that there is always benefit in knowing, but the adverse effects of overdiagnosis are well documented. We will need to educate ourselves and our colleagues about the potential for harm from overdiagnosis, and learn how to balance the potential benefit of a diagnosis against the risk of overdiagnosis.

Factors leading to failure to diagnose pulmonary malignant tumors using endobronchial ultrasound with guide sheath within the target lesion

Background

The diagnostic yield of peripheral pulmonary lesions has significantly increased with the use of radial endobronchial ultrasound with guide sheath within the lesion. Here, we retrospectively evaluated factors leading to misdiagnosis of pulmonary malignant tumors using endobronchial ultrasound with the guide sheath within the lesion.

Methods

We assessed the final histopathological diagnosis of biopsy samples taken from 130 patients with lung malignant tumors that underwent endobronchial ultrasound with guide sheath within the lesion.

Results

Among 130 patients, 8 (6%) showed no definite malignant findings in biopsy samples but the presence of malignant cells (primary lung cancer 7, diffuse large B cell lymphoma 1) was subsequently confirmed by histopathological study of specimens taken by computed tomography-guided needle biopsy or surgery. Of the eight cases with diagnostic failure, the size of the biopsy sample was insufficient in five due to technical difficulties during the diagnostic procedure, and the diagnosis of malignant tumor was difficult in five cases because of extensive scarring tissue or central necrosis.

Conclusions

The results of this study showed that technical difficulties and/or pathological heterogeneity of the tumor might lead to failure to diagnose lung malignant tumor in cases using endobronchial ultrasound with guide sheath within the lesion.

[Clinical characteristics of lung NK/T cell lymphoma misdiagnosed as pneumonia]

Objective: To investigate the clinical features of lung natural killer (NK)/T cell lymphoma. Methods: The clinical data of patients with lung NK/T-cell lymphoma confirmed by pathology who were hospitalized due to lung shadow and initially treated as pneumonia from the First Affiliated Hospital of Zhengzhou University was collected from June 2013 to January 2019. The clinical manifestations, laboratory tests, chest CT findings, treatment procedures, outcomes, and misdiagnosis were retrospectively analyzed. Results: Among the 15 enrolled patients with lung NK/T-cell lymphoma, 5 were primary and the other 10 were secondary. There were 8 males and 7 females, aged 20-76 years. Fever presented in 14 cases, dyspnea was observed in 4 cases and 2 cases had cough. A total of 12 cases had leukopenia, 10 cases had mononuclear cell increase, 10 cases had liver dysfunction, 13 cases had elevated serum lactate dehydrogenase (LDH), and 2 cases of primary lung NK/T-cell lymphoma had increased pleural LDH and adenosine deaminase. Five cases of primary lung NK/T-cell lymphoma had multiple lung lesions, with diffuse multiple solid shadows, ground glass and patchy shadows, some with nodules; 10 cases of secondary lung NK/T-cell lymphoma showed nodular masses, some were accompanied by patchy shadows, and most patients had multiple lesions scattering in the lung. All the fifteen patients were misdiagnosed as pneumonia in the early stage, and then were diagnosed by percutaneous lung biopsy or transbronchial biopsy. Six patients underwent chemotherapy, of which 1 achieved complete response, 4 were in follow-up and 1 died of respiratory failure; 5 patients died of respiratory failure after diagnosis and 4 patients discharged and died within half a year. Conclusions: The lung NK/T-cell lymphoma are rare. The clinical manifestations and pulmonary imaging findings are indistinguishable from pulmonary inflammatory lesions. They are easily misdiagnosed as pneumonia. Early CT-guided percutaneous lung biopsy or transbronchial biopsy can improve the diagnostic accuracy.

Reason for exam Imaging Reporting and Data System (RI-RADS): A grading system to standardize radiology requisitions

Radiologists often encounter imaging requisitions that lack important information needed for accurate diagnostic studies. Reason for exam Imaging Reporting and Data System (RI-RADS) is proposed as a grading system for evaluation of the quality of clinically pertinent information provided in imaging requisitions. Three categories of information are suggested as key indicators of quality: impression, clinical findings, and the diagnostic question. This scheme is intended to improve the quality of imaging requisitions and overall patient care.

Validity of self blood pressure measurement in the control of the hypertensive patient: factors involved

Background

Improving clinical practice aimed at controlling hypertension is a pending issue in health systems. One of the methods currently used for this purpose is self blood pressure measurement (SBPM) whose use increases every day. The aims of this study are to establish the optimal cut-off point for the 3-day SMBP protocol and to identify factors that could affect the precision of the 3-day SMBP protocol using 24-h ambulatory blood pressure monitoring (ABPM) as a reference.

Method

This is a cross-sectional descriptive study to validate a diagnostic test performed by a primary care team in Murcia, Spain. A total of 153 hypertensive patients under 80 years of age who met the inclusion criteria were evaluated. ABPM was performed for 24 h. The SBPM protocol consisted of recording 2 measurements in the morning and 2 at night for 3 days.

Results

The cut-off point for SBP was set at 135 mmHg (sensitivity: 80.39%, specificity: 74.19%), and for DBP, it was set at 83 mmHg (sensitivity: 76.48%, specificity: 84.89%), which yielded the highest combined sensitivity and specificity. After carrying out the validation study with the new figures, we proceeded to establish which socio-demographic factors prevented a correct classification of patients. These errors were more common in male patients for the assessments of both DBP (OR = 2.4) and SBP (OR = 2.5); hypertensive patients with age < 67,5 years (OR = 1,5); having no work activity (OR = 3,6) and with concomitant chronic kidney disease (CKD) (OR = 5.0).

Conclusion

Being male, older than 67.5 years, with CKD or with no work activity increases the probability of being misclassified for hypertension during follow-up as assessed by SBPM over 3 days.

Trial registration

This study was approved by the research ethics committee of the University of Murcia under registration number 1018/2015.

[From symptom to diagnosis-symptom checkers re-evaluated : Are symptom checkers finally sufficient and accurate to use? An update from the ENT perspective]

BACKGROUND

Every seventh diagnosis is a misdiagnosis. Each year, 1.5 million lives could be saved worldwide with the correct diagnosis. Physicians have to consider over 20,000 diseases. A study from Harvard University published in 2015 tested 19 symptom checkers and found them to be insufficient, with only 29-71% accuracy in diagnosis.

OBJECTIVE

The current study investigates the diagnostic accuracy of new symptom checkers from an ENT perspective.

MATERIALS AND METHODS

The authors update the abovenamed diagnostic accuracy comparison by (1) including the five new symptom checkers Symptoma, Ada, FindZebra, Mediktor, and Babylon; and (2) normalizing results of the previously tested symptom checkers as to reflect each diagnostic accuracy based on the same set of patient vignettes. The winner is then compared to the two symptom checkers with the most scientific evidence, namely Isabel and FindZebra, on the basis of an ENT-specific test with patient vignettes sourced from the British Medical Journal.

RESULTS

Most of the new symptom checkers demonstrated diagnostic accuracy rates within the previously established range, with the exception of Symptoma, which scored the right diagnosis in 82.2% of cases at the top of the list (+38% points), and in 100% of cases in the top 3 (+29% points) and the top 10 (+16% points), thus raising the bar in this field. The cross-validation with ENT cases resulted in a diagnostic accuracy of 64.3 vs. 21.4 vs. 26.2% (top 1), 92.9 vs. 40.5 vs. 42.9% (top 3), and 100 vs. 61.9 vs. 54.8% (top 10) for Symptoma vs. Isabel vs. FindZebra, respectively.

CONCLUSIONS

Symptoma is the first and only viable solution in this market. Large-scale studies should be conducted to further validate these results as well as to assess the actual practical performance of the symptom checkers and their ability to diagnose rare diseases.

[Computer-assisted diagnosis of rare diseases]

To establish a comprehensive diagnosis is by far the most challenging task in a physician's daily routine. Especially rare diseases place high demands on differential diagnosis, caused by the high number of around 8000 diseases and their clinical variability. No clinician can be aware of all the different entities and memorizing them all is impossible and inefficient. Specific diagnostic decision-supported systems provide better results than standard search engines in this context. The systems FindZebra, Phenomizer, Orphanet, and Isabel are presented here concisely with their advantages and limitations. An outlook is given to social media usage and big data technologies. Due to the high number of initial misdiagnoses and long periods of time until a confirmatory diagnosis is reached, these tools might be promising in practice to improve the diagnosis of rare diseases.

[Clinical characteristics of malignant peritoneal mesothelioma misdiagnosed as tuberculous peritonitis: a report of 6 cases]

Objective: To reduce the misdiagnosis rate of ascites and improve the diagnosis rate of malignant peritoneal mesothelioma. Methods: From May 2008 to May 2018, in Xiangya Hospital of Central South University,the clinical data of malignant peritoneal mesothelioma misdiagnosed as tuberculous peritonitis were retrospectively analyzed. Results: (1) Among the 6 patients, they were male; the age of onset was 42-70 (52±9.57) years old, and there was no history of asbestos exposure. (2) All cases with abdominal pain or abdominal distension were there and the course of disease was more than 1 month to more than 2 years. (3) In all patients,the nature of ascites was exudate; ADA was higher than normal value and below 45 U/L; LDH value in ascites was higher than 200 U/L (83.3%); mesothelioma was considered in ascites cytology in 1 case. (4) Laparoscopic biopsy was performed in 2 cases and B-ultrasound guided biopsy in 4 cases; Among them, malignant peritoneal mesothelioma diagnosed by pathology. (5) In Immunohistochemical positive markers, MC was the most sensitive (100%), followed by CR (67%), CK-Pan (67%), Ki-67 (67%) and EMA (67%). (6) Two patients received treatment with operation, abdominal hyperthermic perfusion and postoperative systemic chemotherapy. Conclusions: (1) Malignant peritoneal mesothelioma should be considered in middle-aged and aged male patients with unexplained ascites and early laparoscopy or laparotomy for diagnosis. (2) ADA and LDH level in ascites are significant in differentiating tuberculous peritonitis from malignant peritoneal mesothelioma. (3) Immunohistochemical positive marker MC may be a potential specific marker for malignant mesothelioma. (4) The survival time of patients is improved by comprehensive treatment such as operation and chemotherapy.

Cystic Degeneration of Hepatocellular Carcinoma Mimicking Mucinous Cystic Neoplasm

Spontaneous regression of tumors is an extremely rare event in hepatocellular carcinoma (HCC) with only a few reports available. With the accumulation of clinical information and tumor immunogenetics, several mechanisms for the cystic changes of HCC have been suggested, including arterial thrombosis, inflammation, and rapid tumor growth. This paper reports an uncommon case of the partial regression of HCC, which was initially misdiagnosed as a mucinous cystic neoplasm of the liver due to the unusual radiologic findings. A 78-year-old female with the hepatitis B virus and liver cirrhosis presented with an approximately 5 cm-sized cystic mass of the liver. From the radiologic evidence of a papillary-like projection from the cyst wall toward the inner side, the initial impression was a mucinous cystic neoplasm of the liver. The patient underwent a surgical resection and finally, cystic degeneration of HCC, in which approximately 80% necrosis was noted. This case suggests that if a cystic neoplasm of liver appears in a patient with a high risk of HCC on a hepatobiliary imaging study, it is prudent to consider the cystic degeneration of HCC in a differential diagnosis.

Office Patient Safety

Patient safety is inseparable from quality and is a top priority for the United States health care system. This article explores factors that contribute to errors and patient harm in office practice, discusses key ways in which errors in the outpatient setting compare with those occurring in the inpatient setting, and describes strategies for supporting and improving patient safety in office practice.

Unrecognized bipolar disorder in patients with depression managed in primary care: A systematic review and meta-analysis

PURPOSE

Bipolar disorder is a common, severe mental health condition and a major financial burden for healthcare systems across the globe. There is some evidence that unrecognized bipolar disorder is prevalent amongst patients with depression in primary care which can lead to non-optimal treatment. However, a systematic synthesis of this literature is lacking. We aimed to determine the percentage of primary care patients who are diagnosed with depression that have unrecognized bipolar disorder.

METHODS

Medline, Embase, Cochrane and PsycINFO were searched to January 2019. We included quantitative observational studies. Risk of bias was assessed using the Newcastle Ottawa cohort scale. Analyses were performed using random-effects models, heterogeneity was quantified using I² and formal tests of publication bias were undertaken.

RESULTS

Ten studies with 3803 participants with depression in primary care were included. The pooled prevalence of bipolar disorder in those with depression was 17% (95% CI = 12 to 22). The prevalence of unrecognized bipolar depression was higher in studies which used questionnaires as assessment tools for bipolar disorder compared to studies which used clinical interviews but this difference was not significant (14%, 95% CI = 8 to 20 versus 22%, 95% CI = 16 to 28, Q = 1.27, p = 0.12). The prevalence of unrecognized bipolar disorder was not significantly affected by study-level variations in the risk of bias and we found no evidence for publication bias.

CONCLUSION

Over 3 in 20 patients with depression have unrecognized bipolar disorder in primary care which can lead to harmful patient outcomes. Increased awareness of unrecognition of bipolar disorder in primary care patients with depression and efficient assessment strategies in primary care are warranted.

Computed tomographic colonography: how many and how fast should radiologists report?

Objectives

To determine if polyp detection at computed tomographic colonography (CTC) is associated with (a) the number of CTC examinations interpreted per day and (b) the length of time spent scrutinising the scan.

Methods

Retrospective observational study from two hospitals. We extracted Radiology Information System data for CTC examinations from Jan 2012 to Dec 2015. For each examination, we determined how many prior CTCs had been interpreted by the reporting radiologist on that day and how long radiologists spent on interpretation. For each radiologist, we calculated their referral rate (proportion deemed positive for 6 mm+ polyp/cancer), positive predictive value (PPV) and endoscopic/surgically proven polyp detection rate (PDR). We also calculated the mean time each radiologist spent interpreting normal studies (“negative interpretation time”). We used multilevel logistic regression to investigate the relationship between the number of scans reported each day, negative interpretation time and referral rate, PPV and PDR.

Results

Five thousand one hundred ninety-one scans were interpreted by seven radiologists; 892 (17.2%) were reported as positive, and 534 (10.3%) had polyps confirmed. Both referral rate and PDR reduced as more CTCs were reported on a given day (p < 0.001), the odds reducing by 7% for each successive CTC interpreted. Radiologists reporting more slowly than their colleagues detected more polyps (p = 0.028), with each 16% increase in interpretation time associated with a 1% increase in PDR. PPV was unaffected.

Conclusions

Reporting multiple CTCs on a given day and rapid CTC interpretation are associated with decreased polyp detection. Radiologists should be protected from requirements to report too many CTCs or too quickly.

Key Points

• CT colonography services should protect radiologists from a need to report too fast (> 20 min per case) or for too long (> 4 cases consecutively without a break).

• Professional bodies should consider introducing a target minimum interpretation time for CT colonography examinations as a quality marker.

The design and conduct of Project RedDE: A cluster-randomized trial to reduce diagnostic errors in pediatric primary care

BACKGROUND

Diagnostic errors contribute to the large burden of healthcare-associated harm experienced by children. Primary care settings involve high diagnostic uncertainty and limited time and information, creating ideal conditions for diagnostic errors. We report on the design and conduct of Project RedDE, a stepped-wedge, cluster-randomized controlled trial of a virtual quality improvement collaborative aimed at reducing diagnostic errors in pediatric primary care.

METHODS

Project RedDE cluster-randomized pediatric primary care practices into one of three groups. Each group participated in a quality improvement collaborative targeting the same three diagnostic errors (missed diagnoses of elevated blood pressure and adolescent depression and delayed diagnoses of abnormal laboratory studies), but in a different sequence. During the quality improvement collaborative, practices worked both independently and collaboratively, leveraging general quality improvement strategies (e.g. process mapping) in addition to error-specific content (e.g. pocket guides for blood pressure norms) delivered during the intervention phase for each error. The quality improvement collaborative intervention included interactive learning sessions and webinars, quality improvement coaching at the team level, and repeated evaluation of failures via root cause analyses. Pragmatic data were collected monthly, submitted to a centralized data aggregator, and returned to the practices in the form of run charts comparing each practice's progress over time to that of the group. The primary analysis used patients as the unit of analysis and compared diagnostic error proportions between the intervention and baseline periods, while secondary analyses evaluated the sustainability of observed reductions in diagnostic errors after the intervention period ended.

RESULTS

A total of 43 practices were recruited and randomized into Project RedDE. Eleven practices withdrew before submitting any data, and one practice merged with another participating practice, leaving 31 practices that began work on Project RedDE. All but one of the diverse, national pediatric primary care practices that participated ultimately submitted complete data. Quality improvement collaborative participation was robust, with an average of 63% of practices present on quality improvement collaborative webinars and 85% of practices present for quality improvement collaborative learning sessions. Complete data included 30 months of outcome data for the first diagnostic error worked on, 24 months of outcome data for the second, and 16 months of data for the third.

LESSONS LEARNED AND LIMITATIONS

Contamination across study groups was a recurring concern; concerted efforts were made to mitigate this risk. Electronic health records played a large role in teams' success.

CONCLUSION

Project RedDE, a virtual quality improvement collaborative aimed at reducing diagnostic errors in pediatric primary care, successfully recruited and retained a diverse, national group of pediatric primary care practices. The stepped-wedge, cluster-randomized controlled trial design allowed for enhanced scientific efficiency.

Spectrum of diagnostic errors in cervical spine trauma imaging and their clinical significance

PURPOSE

To describe and categorize diagnostic errors in cervical spine CT (CsCT) interpretation performed for trauma and to assess their clinical significance.

METHODS

All CsCTs performed for trauma with diagnostic errors that came to our attention based on clinical or imaging follow-up or quality assurance peer review from 2004 to 2017 were included. The number of CsCTs performed at our institution during the same time interval was calculated. Errors were categorized as spinal/extraspinal, involving osseous/soft tissue structures, by anatomical site and level. Images were reviewed by a radiologist and two spine surgeons. For each error, the need for surgery, immobilization, CT angiogram of the neck, and MRI was assessed; if any of these were needed, the error was considered clinically significant.

RESULTS

Of an approximate total 59,000 CsCTs, 56 reports containing diagnostic errors were included. Twelve were extraspinal, and 44 were spinal (26 fractures, 15 intervertebral disc protrusions, two subluxations, one lytic bone lesion). The most common sites of spinal fractures were vertebral body (n = 10) and transverse process (n = 8); the most common levels were C5 (n = 8) and C7 (n = 6). All (n = 26) fractures and two atlantooccipital subluxations were considered clinically significant, including three patients who would have required urgent surgical stabilization (two subluxations and one facet fracture). Two transverse processes fractures did not alter the need for surgical intervention/surgical approach, immobilization, or MRI.

CONCLUSIONS

In our study, 66% of spinal diagnostic errors on CsCT were considered clinically significant, potentially altering clinical management. Transverse process and vertebral body fractures were commonly missed.

Computer-assisted detection of metastatic lung tumors on computed tomography

BACKGROUND

This retrospective study examined the performance of computer-assisted detection in the identification of pulmonary metastases.

METHODS

Fifty-five patients (41.8% male) who underwent surgery for metastatic lung tumors in our hospital from 2005 to 2012 were included. Computer-assisted detection software configured to display the top five nodule candidates according to likelihood was applied as the first reader for the preoperative computed tomography images. Results from the software were classified as "metastatic nodule", "benign nodule", or "false-positive finding" by two observers.

RESULTS

Computer-assisted detection identified 85.3% (64/75) of pulmonary metastases that radiologists had detected, and 3 more (4%, 3/75) that radiologists had overlooked. Nodule candidates identified by computer-assisted detection included 86 benign nodules (median size 3.1 mm, range 1.2-18.7 mm) and 121 false-positive findings.

CONCLUSIONS

Computer-assisted detection identified pulmonary metastases overlooked by radiologists. However, this was at the cost of identifying a substantial number of benign nodules and false-positive findings.