Ectopic pregnancy: a malpractice paradigm

Perceptual error and the culture of open disclosure in Australian radiology

The work of diagnostic radiology consists of the complete detection of all abnormalities in an imaging examination and their accurate diagnosis. Errors in diagnostic radiology comprise perceptual errors, which are a failure of detection, and interpretation errors, which are errors of diagnosis. Perceptual errors are subject to rules of human perception and can be expected in a proportion of observations by any human observer including a trained professional under ideal conditions. Current legal standards of medical negligence make no allowance for perceptual errors, comparing human performance to an ideal standard. Diagnostic radiology in Australia has a culture of open disclosure, where full unbiased evidence from an examination is provided to the patient together with the report. This practice benefits the public by allowing genuine differences of opinion and also by allowing a second chance of correct diagnosis in cases of perceptual error. The culture of open disclosure, which is unique to diagnostic radiology, places radiologists at distinct medicolegal disadvantage compared with other specialties. (i) Perceptual error should be acknowledged as an integral inevitable part of diagnostic radiology; (ii) culture of open disclosure should be encouraged by the profession; and (iii) a pragmatic definition of medical negligence should reflect the imperfect performance of human observers.

Ultrasound in pregnancy

Ultrasound represents the cornerstone of the emergent evaluation of pregnancy-related complaints. Knowledge of the potential and the limitations of this imaging modality, regardless of who performs it, is important for physicians who evaluate and manage these patients and their unborn children in the ED.

Diagnosing unruptured ectopic pregnancy

OBJECTIVE

A retrospective analysis of the management of ectopic pregnancy at Korle Bu Teaching Hospital in Accra, Ghana, to assess the impact of the introduction of ultrasonography as a diagnostic tool.

METHODS

All charts of patients with ectopic pregnancies from 1 January 1986 to 31 December 1990 were analyzed. The management of those patients who had transabdominal ultrasonography was compared with those who had not.

RESULTS

The use of ultrasonography increased the number of unruptured ectopic pregnancies from 0.3% to 8.5% (P < 0.001). This also reflected a reduction in misdiagnoses, blood transfusions, and maternal deaths.

CONCLUSIONS

The reasonable use of modern technology can be of great assistance even in developing countries, as shown by the positive impact of the use of ultrasonography to aid in the diagnosis of ectopic pregnancy in Ghana, West Africa.

Emergency department sonography by emergency physicians

A retrospective study was conducted to examine whether emergency physicians can perform accurate ultrasonography that influences the diagnosis and treatment of selected disorders in the emergency department (ED). The physicians acquired a moderate level of expertise in sonography using a series of practical demonstrations and lectures. Patients with symptoms suggestive of cardiac, gynecologic, biliary tract, and abdominal vascular disease periodically underwent ED sonography. The initial interpretation was used as a diagnostic adjunct to subsequent therapy. The accuracy of positive sonographic findings was assessed by confirmatory testing, formal review, or confirmatory clinical course. Emergency physicians were able to diagnose correctly (1) the presence and approximate size of pericardial effusions, (2) the presence or absence of organized cardiac activity in patient with clinical electrical mechanical dissociation, (3) the presence or absence of intrauterine pregnancy in pregnant patients with lower abdominal/pelvic complaints, (4) the position of intrauterine devices in patients with suspected uterine perforation, (5) the presence of gallstones in patients with suspected biliary tract disease, and (6) the presence and size of abdominal aortic aneurysms in patients with pulsatile masses or unexplained abdominal pain. It was concluded that reliable sonography which influences diagnosis and therapy can be performed by emergency physicians and that sonography should become a standard procedure in EDs.