Perceptual error and the culture of open disclosure in Australian radiology

Best Practices in Modified Barium Swallow Studies

Purpose The modified barium swallow study (MBSS) is a widely used videofluoroscopic evaluation of the functional anatomy and physiology of swallowing that permits visualization of bolus flow throughout the upper aerodigestive tract in real time. The information gained from the examination is critical for identifying and distinguishing the type and severity of swallowing impairment, determining the safety of oral intake, testing the effect of evidence-based frontline interventions, and formulating oral intake recommendations and treatment planning. The goal of this review article is to provide the state of the science and best practices related to MBSS. Method State of the science and best practices for MBSS are reviewed from the perspectives of speech-language pathologists (SLPs) and radiologists who clinically practice and conduct research in this area. Current quandaries and emerging clinical and research trends are also considered. Results This document provides an overview of the MBSS and standards for conducting, interpreting, and reporting the exam; the SLPs' and radiologist's perspectives on standardization of the exam; radiation exposure; technical parameters for recording and reviewing the exam; the importance of an interdisciplinary approach with engaged radiologists and SLPs; and special considerations for examinations in children. Conclusions The MBSS is the primary swallowing examination that permits visualization of bolus flow and swallowing movement throughout the upper aerodigestive tract in real time. The clinical validity of the study has been established when conducted using reproducible and validated protocols and metrics applied according to best practices to provide accurate and reliable information necessary to direct treatment planning and limit radiation exposure. Standards and quandaries discussed in this review article, as well as references, provide a basis for understanding the current best practices for MBSS.

Prevalence and clinical significance of discordant LI-RADS® observations on multiphase contrast-enhanced MRI in patients with cirrhosis

PURPOSE

To determine the prevalence and clinical significance of discordant LI-RADS^® (Liver Imaging Reporting and Data System) liver observations on multiphase contrast-enhanced (MCE) magnetic resonance imaging (MRI) in patients with cirrhosis.

METHODS

This cross-sectional study included 93 cirrhosis patients who underwent 1.5 or 3 T MCE MRI for evaluation of hepatocellular carcinoma (HCC). Two abdominal radiologists independently reviewed T1-, T2-, diffusion-weighted unenhanced images as well as MCE T1-weighted fat-suppressed images and reported liver observations using LI-RADS^®. Concordance were recorded for detection (co-detected by both radiologists or not), size category (< 10; 10-19; ≥ 20 mm), and LI-RADS^® category assignment as reportable (LR-3/4/5/M) and actionable (LR-4/5/M). The overall concordance (i.e., concordant in detection, size, and LR-category) was calculated with 95% confidence interval [CI], and separately for detection, size, and LR-category. Clinical significance of discordance was assessed as impact on follow-up imaging, referral for biopsy, liver transplant eligibility, or treatment modality.

RESULTS

Reportable and actionable observations were overall concordant between two radiologists only in 32.3% [24.6, 41.0] and 40.1% [29.5, 51.5] of cases, respectively. Poor overall concordance was related to detection concordance of 52.0% [44.3, 59.5] and 62.5% [52.3, 71.8], as well as LR-category concordance of 73.7% [61.6, 83.1] and 70.9% [57.3, 81.6], for reportable and actionable observations, respectively. Discordant LI-RADS^® observations would have impacted clinical management in 30 subjects (43.5%), most (66.7%) of whom were due to discordant detection.

CONCLUSION

Discordant MRI LI-RADS^® observations are common in patients with cirrhosis and may have potential implications for patient management.

Factors affecting perception of the normal pediatric appendix on sonography

Background

To determine if an inherent perception skill along with sonographer experience, knowledge base, scanning time play a role in the identification of the normal appendix in the pediatric population. This is a retrospective review of pediatric (< 18 years old) patients with a clinical suspicion of acute appendicitis presenting to the emergency department of two affiliated academic tertiary care hospitals over a 1-year time span. All patients had a sonogram performed by 1/15 sonographers or by 1/8 on-call radiology residents. Those with a normal or non-visualized appendix with subsequent discharge from ER were included in the study. Patient demographics, minutes spent scanning, and sonographer years of experience in general abdominal scanning and residents level of training were recorded.

Results

Of the 127 patients included in the study, 51 (40%) were male and 76 (60%) were female, with a mean age of 11.8 ± 4.2 years. Sonographers who failed to see a normal appendix had less experience (median 8 years) than those who did visualize the appendix (median 15 years), p ≤ 0.001. Longer time spent scanning was also associated with visualizing a normal appendix (20.4 versus 29.1 min, p = 0.001). In multivariable logistic regression, more time spent scanning (OR 1.04, 95% CI 1.01, 1.07, p = 0.012) and increased sonographer experience (OR 1.07, 95% CI 1.02, 1.13, p = 0.012) resulted in greater odds of perceiving the appendix. The top 4 were significantly more likely to visualize the appendix (88.0%) than all of the other combined (20.8%, p < 0.001), and they also had substantially more experience (median 15 years versus 8 years, p < 0.001). Overall, sonographers were more likely to see a normal appendix (61%) than the residents (14%), p < 0.001.

Conclusion

Sonography to rule out appendicitis in the pediatric patient is in general most successful when performed by experienced sonographers with adequate time to perform the scan. Triaging patients to those sonographers who have displayed optimal perceptual ability of the normal appendix may help optimize patient care and hospital resources. Having experienced sonographers available after hours would allow for optimal care in the setting of ‘query’ appendicitis.

Effect of 3-Dimensional Virtual Reality Models for Surgical Planning of Robotic-Assisted Partial Nephrectomy on Surgical Outcomes: A Randomized Clinical Trial

IMPORTANCE

Planning complex operations such as robotic-assisted partial nephrectomy requires surgeons to review 2-dimensional computed tomography or magnetic resonance images to understand 3-dimensional (3-D), patient-specific anatomy.

OBJECTIVE

To determine surgical outcomes for robotic-assisted partial nephrectomy when surgeons reviewed 3-D virtual reality (VR) models during operative planning.

DESIGN, SETTING, AND PARTICIPANTS

A single-blind randomized clinical trial was performed. Ninety-two patients undergoing robotic-assisted partial nephrectomy performed by 1 of 11 surgeons at 6 large teaching hospitals were prospectively enrolled and randomized. Enrollment and data collection occurred from October 2017 through December 2018, and data analysis was performed from December 2018 through March 2019.

INTERVENTIONS

Patients were assigned to either a control group undergoing usual preoperative planning with computed tomography and/or magnetic resonance imaging only or an intervention group where imaging was supplemented with a 3-D VR model. This model was viewed on the surgeon's smartphone in regular 3-D format and in VR using a VR headset.

MAIN OUTCOMES AND MEASURES

The primary outcome measure was operative time. It was hypothesized that the operations performed using the 3-D VR models would have shorter operative time than those performed without the models. Secondary outcomes included clamp time, estimated blood loss, and length of hospital stay.

RESULTS

Ninety-two patients (58 men [63%]) with a mean (SD) age of 60.9 (11.6) years were analyzed. The analysis included 48 patients randomized to the control group and 44 randomized to the intervention group. When controlling for case complexity and other covariates, patients whose surgical planning involved 3-D VR models showed differences in operative time (odds ratio [OR], 1.00; 95% CI, 0.37-2.70; estimated OR, 2.47), estimated blood loss (OR, 1.98; 95% CI, 1.04-3.78; estimated OR, 4.56), clamp time (OR, 1.60; 95% CI, 0.79-3.23; estimated OR, 11.22), and length of hospital stay (OR, 2.86; 95% CI, 1.59-5.14; estimated OR, 5.43). Estimated ORs were calculated using the parameter estimates from the generalized estimating equation model. Referent group values for each covariate and the corresponding nephrometry score were summed across the covariates and nephrometry score, and the sum was exponentiated to obtain the OR. A mean of the estimated OR weighted by sample size for each nephrometry score strata was then calculated.

CONCLUSIONS AND RELEVANCE

This large, randomized clinical trial demonstrated that patients whose surgical planning involved 3-D VR models had reduced operative time, estimated blood loss, clamp time, and length of hospital stay.

TRIAL REGISTRATION

ClinicalTrials.gov identifiers (1 registration per site): NCT03334344, NCT03421418, NCT03534206, NCT03542565, NCT03556943, and NCT03666104.

A new approach for detecting abnormalities in mammograms using a computer-aided windowing system based on Otsu's method

Breast cancer is the most common cancer and the leading cause of cancer deaths in women worldwide. This study aimed to provide an automatic windowing method in mammograms, based on the principles of Otsu's thresholding function, to help radiologists more easily detect abnormalities on mammograms. A total of 322 mammographic images from the Mammographic Image Analysis Society (MIAS) database were used in the present study. The image background was removed based on Otsu's method. After selecting the threshold in the computer-aided windowing (CAW) system, the pixel values were kept larger than the threshold and displayed on a grayscale. A radiologist evaluated images randomly before and after CAW. Using CAW, the radiologist correctly diagnosed all healthy images (207 images). A total of 115 mammograms were evaluated to differentiate malignancy from benign masses. All 63 benign images were accurately diagnosed after using CAW. Moreover, of 52 malignant images, all were accurately recognized as malignant except one, which was recognized as benign. Therefore, specificity and sensitivity were significantly improved to 98% and 99.6%, respectively, and the area under the receiver operating characteristic (ROC) curve was calculated to be 0.99. The study showed that the use of CAW can potentially lead to quicker image assessment and improve the diagnostic accuracy of radiologists in differentiating between benign and malignant masses on mammograms.

Evidence-based anatomical review areas derived from systematic analysis of cases from a radiological departmental discrepancy meeting

AIM

To produce short checklists of specific anatomical review sites for different regions of the body based on the frequency of radiological errors reviewed at radiology discrepancy meetings, thereby creating "evidence-based" review areas for radiology reporting.

MATERIALS AND METHODS

A single centre discrepancy database was retrospectively reviewed from a 5-year period. All errors were classified by type, modality, body system, and specific anatomical location. Errors were assigned to one of four body regions: chest, abdominopelvic, central nervous system (CNS), and musculoskeletal (MSK). Frequencies of errors in anatomical locations were then analysed.

RESULTS

There were 561 errors in 477 examinations; 290 (46%) errors occurred in the abdomen/pelvis, 99 (15.7%) in the chest, 117 (18.5%) in the CNS, and 125 (19.9%) in the MSK system. In each body system, the five most common location were chest: lung bases on computed tomography (CT), apices on radiography, pulmonary vasculature, bones, and mediastinum; abdominopelvic: vasculature, colon, kidneys, liver, and pancreas; CNS: intracranial vasculature, peripheral cerebral grey matter, bone, parafalcine, and the frontotemporal lobes surrounding the Sylvian fissure; and MSK: calvarium, sacrum, pelvis, chest, and spine.

CONCLUSION

The five listed locations accounted for >50% of all perceptual errors suggesting an avenue for focused review at the end of reporting.

Incidental and Underreported Pleural Plaques at Chest CT: Do Not Miss Them-Asbestos Exposure Still Exists

Pleural plaques (PPs) may be a risk factor for mortality from lung cancer in asbestos-exposed workers and are considered to be a marker of exposure. Diagnosing PPs is also important because asbestos-exposed patients should be offered a health surveillance that is mandatory in many countries. On the other hand PPs are useful for compensation purposes. In this study we aimed to evaluate the prevalence, as incidental findings, and the underreporting rate of PPs in chest CT scans (CTs) performed in a cohort of patients (1512) who underwent chest CT with a slice thickness no more than 1.25 mm. PPs were found in 76 out of 1482 patients (5.1%); in 13 out of 76 (17,1%) CTs were performed because of clinical suspicion of asbestos exposure and 5 of them (38%) were underreported by radiologist. In the remaining 63 cases (82.9%) there was no clinical suspicion of asbestos exposure at the time of CTs (incidental findings) and in 38 of these 63 patients (60.3%) PPs were underreported. Reaching a correct diagnosis of PPs requires a good knowledge of normal locoregional anatomy and rigorous technical approach in chest CT execution. However the job history of the patient should always be kept in mind.

Errors in imaging of traumatic injuries

The advent of multi-detector computed tomography (MDCT) has drastically improved the outcomes of patients with multiple traumatic injuries. However, there are still diagnostic challenges to be considered. A missed or the delay of a diagnosis in trauma patients can sometimes be related to perception or other non-visual cues, while other errors are due to poor technique or poor image quality. In order to avoid any serious complications, it is important for the practicing radiologist to be cognizant of some of the most common types of errors. The objective of this article is to review the various types of errors in the evaluation of patients with multiple trauma injuries or polytrauma with MDCT.

The 'radiographer-referrer game': image interpretation dynamics in rural practice

INTRODUCTION

Effective interprofessional communication is intrinsic to safe health care. Despite the identified positive impact of collaborative radiographic interpretation between rural radiographers and referrers, communication difficulties still exist. This article describes the strategies that Australian rural radiographers use for communication of their radiographic opinion to the referring doctor.

METHODS

In a two-phase interpretive doctoral study completed in 2012, data were collected from radiographers working in rural New South Wales, Western Australia and Tasmania using a paper based questionnaire followed by in-depth semistructured interviews. Data were analysed thematically in order to identify, analyse and report the emergent themes.

RESULTS

The overarching theme was Patient Advocacy, where in the interest of patient care radiographers took measures to ensure that a referring doctor did not miss radiographic abnormalities. Strong interprofessional relationships enabled direct communication pathways. Interprofessional boundaries shaped by historical hierarchical relationships, together with a lack of confidence and educational preparation for radiographic interpretation result in barriers to direct communication pathways. These barriers prompted radiographers to pursue indirect communication pathways, such as side-stepping and hint and hope.

CONCLUSION

A lack of formal communication pathways and educational preparation for this role has resulted in radiographers playing the radiographer-referrer game to overtly or covertly assist referrers in reaching a radiographic diagnosis. The findings from this study may be used to plan interventions for strengthening interprofessional communication pathways and improve quality of healthcare for patients.

Errors in multidetector row computed tomography

Multidetector row computed tomography (MDCT) represents the technique of choice for the majority of pathologies today and is responsible for the majority of diagnoses. However, despite the low number of studies dedicated to errors in MDCT, CT reporting seems especially prone to generating errors and errors are an inevitable part of MDCT practice. Most of these arise during image interpretation but, differently from other radiological techniques, the awareness of radiologists regarding technical CT aspects and pathologies substantially contribute in generating errors, in particular because CT technology expands rapidly and radiologists do not routinely receive specific and appropriate training for its use and because CT examinations are not the same for each patient and each pathology and the choice of the most appropriate CT examination (including the dose exposure to the patient) presumes a very large awareness from radiologists. This review is aimed at increasing awareness regarding the type of errors in MDCT and in particular to also highlight technical and procedural errors.

Sources of error in emergency ultrasonography

BACKGROUND

To evaluate the common sources of diagnostic errors in emergency ultrasonography.

METHODS

The authors performed a Medline search using PubMed (National Library of Medicine, Bethesda, Maryland) for original research and review publications examining the common sources of errors in diagnosis with specific reference to emergency ultrasonography. The search design utilized different association of the following terms : (1) emergency ultrasonography, (2) error, (3) malpractice and (4) medical negligence. This review was restricted to human studies and to English-language literature. Four authors reviewed all the titles and subsequent the abstract of 171 articles that appeared appropriate. Other articles were recognized by reviewing the reference lists of significant papers. Finally, the full text of 48 selected articles was reviewed.

RESULTS

Several studies indicate that the etiology of error in emergency ultrasonography is multi-factorial. Common sources of error in emergency ultrasonography are: lack of attention to the clinical history and examination, lack of communication with the patient, lack of knowledge of the technical equipment, use of inappropriate probes, inadequate optimization of the images, failure of perception, lack of knowledge of the possible differential diagnoses, over-estimation of one's own skill, failure to suggest further ultrasound examinations or other imaging techniques.

CONCLUSIONS

To reduce errors in interpretation of ultrasonographic findings, the sonographer needs to be aware of the limitations of ultrasonography in the emergency setting, and the similarities in the appearances of various physiological and pathological processes. Adequate clinical informations are essential. Diagnostic errors should be considered not as signs of failure, but as learning opportunities.

The concept of error and malpractice in radiology

Since the early 1970s, physicians have been subjected to an increasing number of medical malpractice claims. Radiology is one of the specialties most liable to claims of medical negligence. The etiology of radiological error is multifactorial. Errors fall into recurrent patterns. Errors arise from poor technique, failures of perception, lack of knowledge, and misjudgments. Every radiologist should understand the sources of error in diagnostic radiology as well as the elements of negligence that form the basis of malpractice litigation. Errors are an inevitable part of human life, and every health professional has made mistakes. To improve patient safety and reduce the risk from harm, we must accept that some errors are inevitable during the delivery of health care. We must play a cultural change in medicine, wherein errors are actively sought, openly discussed, and aggressively addressed.

Errors in imaging assessment of polytrauma patients

Although the use of multidetector computed tomography (MDCT) has increased the diagnostic quality by reducing the number of missed diagnoses in polytraumatized patients, errors remain a common phenomenon in emergency room setting. MDCT errors, contributing more commonly to missed or delayed diagnoses in polytrauma patients, are diagnostic errors commonly related to perceptual errors or to nonvisual errors. However, in some cases, misdiagnoses can be attributed to technical and methodological errors leading to incomplete or poor-quality imaging. Knowledge of common patterns of error is the most effective way to avoid future errors. The purpose of this article is to highlight the most frequent types of diagnostic errors in evaluating with MDCT of polytrauma patients.

Common patterns in 558 diagnostic radiology errors

INTRODUCTION

As a Quality Improvement initiative our department has held regular discrepancy meetings since 2003. We performed a retrospective analysis of the cases presented and identified the most common pattern of error.

METHODS

A total of 558 cases were referred for discussion over 92 months, and errors were classified as perceptual or interpretative. The most common patterns of error for each imaging modality were analysed, and the misses were scored by consensus as subtle or non-subtle.

RESULTS

Of 558 diagnostic errors, 447 (80%) were perceptual and 111 (20%) were interpretative errors. Plain radiography and computed tomography (CT) scans were the most frequent imaging modalities accounting for 246 (44%) and 241 (43%) of the total number of errors, respectively. In the plain radiography group 120 (49%) of the errors occurred in chest X-ray reports with perceptual miss of a lung nodule occurring in 40% of this subgroup. In the axial and appendicular skeleton missed fractures occurred most frequently, and metastatic bone disease was overlooked in 12 of 50 plain X-rays of the pelvis or spine. The majority of errors within the CT group were in reports of body scans with the commonest perceptual errors identified including 16 missed significant bone lesions, 14 cases of thromboembolic disease and 14 gastrointestinal tumours. Of the 558 errors, 312 (56%) were considered subtle and 246 (44%) non-subtle.

CONCLUSION

Diagnostic errors are not uncommon and are most frequently perceptual in nature. Identification of the most common patterns of error has the potential to improve the quality of reporting by improving the search behaviour of radiologists.

Terms used to describe pediatric videofluoroscopic feeding studies: a Delphi survey

BACKGROUND

The prevalence of pediatric feeding and swallowing disorders is high in the special needs population. Videofluoroscopic feeding studies (VFFS) are used to assess feeding, but the accurate interpretation of VFFS depends on consistent use of terminology for describing a physiological swallow. No consensus exists regarding the terminology used for reporting VFFS findings.

PURPOSE

The goal of this study was to achieve consensus among pediatric therapists on definitions for terminology used to describe the results of VFFS.

METHODS

Using a Delphi process, therapists from British Columbia rated definitions most appropriate for each term. They also were asked to add definitions that they thought would more accurately describe the terms. FINDINGS. Consensus was achieved on at least one definition for each of the terms used to describe the results of VFFS.

IMPLICATIONS

Accurate interpretation of swallowing issues may improve the care of infants and children with feeding and swallowing difficulties.

Learning from diagnostic errors: a good way to improve education in radiology

PURPOSE

To evaluate the causes and the main categories of diagnostic errors in radiology as a method for improving education in radiology.

MATERIAL AND METHODS

A Medline search was performed using PubMed (National Library of Medicine, Bethesda, MD) for original research publications discussing errors in diagnosis with specific reference to radiology. The search strategy employed different combinations of the following terms: (1) diagnostic radiology, (2) radiological error and (3) medical negligence. This review was limited to human studies and to English-language literature. Two authors reviewed all the titles and subsequently the abstracts of 491 articles that appeared pertinent. Additional articles were identified by reviewing the reference lists of relevant papers. Finally, the full text of 75 selected articles was reviewed.

RESULTS

Several studies show that the etiology of radiological error is multi-factorial. The main category of claims against radiologists includes the misdiagnoses. Radiologic "misses" typically are one of two types: either missed fractures or missed diagnosis of cancer. The most commonly missed fractures include those in the femur, the navicular bone, and the cervical spine. The second type of "miss" is failure to diagnose cancer. Lack of appreciation of lung nodules on chest radiographs and breast lesions on mammograms are the predominant problems.

CONCLUSION

Diagnostic errors should be considered not as signs of failure, but as learning opportunities.

Spectrum of diagnostic errors in radiology

Diagnostic errors are important in all branches of medicine because they are an indication of poor patient care. Since the early 1970s, physicians have been subjected to an increasing number of medical malpractice claims. Radiology is one of the specialties most liable to claims of medical negligence. Most often, a plaintiff's complaint against a radiologist will focus on a failure to diagnose. The etiology of radiological error is multi-factorial. Errors fall into recurrent patterns. Errors arise from poor technique, failures of perception, lack of knowledge and misjudgments. The work of diagnostic radiology consists of the complete detection of all abnormalities in an imaging examination and their accurate diagnosis. Every radiologist should understand the sources of error in diagnostic radiology as well as the elements of negligence that form the basis of malpractice litigation. Error traps need to be uncovered and highlighted, in order to prevent repetition of the same mistakes. This article focuses on the spectrum of diagnostic errors in radiology, including a classification of the errors, and stresses the malpractice issues in mammography, chest radiology and obstetric sonography. Missed fractures in emergency and communication issues between radiologists and physicians are also discussed.

Ethical problems in radiology: medical error and disclosure

In radiological practice, as in any medical activity, errors are inevitable despite being foreseeable and preventable. The approach to managing medical error and relations with patients prompt the need for resolving the ethical dilemma arising from conflicting legitimate interests. The solution to this dilemma is particularly complex in an environment in which the tendency to sue physicians for civil liability or incriminate them for criminal liability appears to be particularly high. The disclosure of error is undeniably useful in raising patient awareness, reducing their suffering, improving the quality of care and limiting the consequences of the damage. There does not appear to be any evidence to suggest disclosure modifies the probability of litigation against the physician.

Food For Thought: Self-Criticism and Raising the Bar of Dysphagia Practice

The assessment and treatment of swallowing disorders have become central to the practice of the medical speech-language pathologist. The outcomes associated with swallowing and swallowing disorders are severe with aspiration pneumonia, malnutrition and dehydration, and reduced quality of life among the most concerning. Clinicians practicing in this area possess unequal skills, training, and experience, and there is considerable variation in practice in the field. This article focuses on variation and error in swallowing assessment with attention to reliability and accuracy of the videofluoroscopic swallowing assessment. In this self-critical overview of the practice, recommendations are made for developing a standardized assessment protocol, shared lexicon, and specialty recognition in the area of swallowing and swallowing disorders.

A quality assurance elective for radiology residents

RATIONALE AND OBJECTIVES

As a component of the practice-based core competency of the Accreditation Council for Graduate Medical Education, all radiology residents must receive training to be able to evaluate and improve their patient care practices. To achieve this goal, our quality management section has implemented a comprehensive elective rotation in quality assurance.

MATERIALS AND METHODS

We have designed a month-long structured resident elective in radiology quality assurance at the Beth Israel Deaconess Medical Center, Harvard Medical School. This elective provides a combination of didactic teaching, self-learning, and practical experience in the methodology, workings, and clinical applications of quality assurance as these relate to improving technical and clinical performance in a large academic radiology department.

RESULTS

During this rotation, residents are exposed to the spectrum of commonly used tools and techniques used for performance improvement related to the practice of radiology. By actively participating in department and hospital quality assurance (QA) committee meetings, and through initiation of a mentored project coupled with didactic instruction, residents are exposed first hand to the practice and role of continuous quality monitoring and to the implementation and monitoring of action items.

CONCLUSION

Participation in our QA elective provides our residents with a comprehensive exposure to the spectrum of quality-related problems, and equips them with the necessary tools to resolve many of the clinical or technical problems they are likely to encounter in their future careers. It is thus an appropriate tool to instruct residents in the competency of "practice-based learning and improvement."