To Err Is Human


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As radiologists, we all make mistakes. The article is to look why we mistakes and how to rectify them.

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To Err Is Human

  1. 1. To Err is Human
  2. 2. Introduction “We all make mistakes, and we all presume we learn from our mistakes. The wise person is one who learns from others’ mistakes!” – Anonymous We, the radiologists, fear our failures and mistake the most. The worst fear is missing the obvious, or a life threatening finding. Medicolegal litigations exponentially increase our “fear of failure”. Nobody gives any credit, when a 23 year pregnant lady undergoes CTPA for suspected pulmonary embolism, you make a confident diagnosis of “tuberous sclerosis” by the combining the findings of spontaneous pneumothorax, a few small cysts in both lungs, and a focal bulge in the right kidney (angiomyolipoma) seen on the last slice. The clinicians presume the diagnosis was written all over the CT scan! Imagine you missed a thrombosis in the common femoral vein which was seen on the last slice of the CT abdomen, and was pointed out by your colleague in one of the meetings. Your day or the week fills with misery and depression. You start looking for venous thrombosis in all CT scans till it becomes a routine habit, or you once again forget to look at veins on CT abdomen. "Nothing is more intolerable than to have to admit to yourself your own errors" - Beethoven (German composer) After all, we are human beings. We get carried away by the clinical information; we succumb to the pressure of the work; we are engulfed in our personalities, biases, prejudices, and limitations of our knowledge and skill. We all make mistake, and the bottom line is mistakes are unavoidable in radiology. The more we report, the more mistakes we make (numerically); but at the same time we tend to make lesser mistakes (percentage)! We all want to make less mistakes so that we can help clinicians to make right decisions at right time. We want to give the best value for money spent on the radiological investigations. We also want to safeguard ourselves against the medicolegal litigations. Benjamin Franklin told "To err is human, to repent divine, to persist devilish". In next few series of blogs, let us review the literature of mistakes in radiology and learn the tricks of minimising them.
  3. 3. Our work place is like a fish market! The sooner you make your first five thousand mistakes, the sooner you will be able to correct them - Kimon Nicolaides (American Art Teacher 1891-1938) We are constantly disturbed by our secretaries ("so and so doctor wants urgent report of this"), radiographers ("can you review this child's elbow x-ray?"), colleagues ("I want to show you an interesting MRI"), fellow clinicians ("can I order an urgent CTPA?"), and registrars/ residents ("I am doing barium enema and have a doubt, can you come have a look?"). We are constantly disturbed by the phone calls from all departments of the hospital, "I am a junior doctor from casualty, we need urgent CT for a patient with head injury with GCS of 12", "I am consultant urologist, can you show me the pulmonary nodule which you reported one of my patients", "I am Prof.ABCD. Can you give a lecture next week to medicine PGs regarding uses of MRI?"...trin trin...never ending! We are constantly disturbed by the mobile phone, "My son, how are you? did you have your breakfast?", "Darling, do not forget that we are going to a movie tonight", "Arre yaar, how are you? The last time we met you were still a resident", "Hello, I am calling on behalf of XYZ bank, do you want a credit card?". We are constantly disturbed by internet, "IPL live score" sitting in a corner, "you have 10 unread e-mails" in outlook, "25 reports to check and sign" in the reporting folder, a half written paper, a PDF of a journal article to be read, and intersting images to download to the pen-drive, a half cooked power-point presentation for the talk next week. In between all these, most of the time we do sensible reporting, and sometimes we do make mistakes!
  4. 4. Where all can we go wrong and what to do about them? "If everything seems to be going well, you have obviously overlooked something" - Murphy's law We keep reading blunders and mistakes done by the radiologists in various newspapers, tabloids, blogs, websites and journals from funny non-harmful silly mistakes to paying huge amount of compensation. The bottom line is we are no way superior to our colleagues who committed those mistakes, and we can commit similar mistakes anytime in our career. There is always a risk of accident when you are driving; there is always a risk of making mistakes when you are reporting! Things can go wrong from typographical error to missing pneumothorax to missing an adrenal mass to puncturing a carotid artery instead of jugular vein. Things can go wrong from early morning headache to constant disturbances to complete mental fatigue (at the end of the day, we start reporting "nothing can be excluded on these images!). If we become more careful, our work slows down, not the number of errors. If we start spending more time looking for abnormalities in a single radiograph till we finish 100 check- list (typed and kept by the side), our eyes and brain will be fatigued in reading 10 films a day. The solution does not lie in having a check list by the side or keep looking at images for hours together, the solution lies in restructuring our work pattern, and redesigning the way we look, the way we report, and the way we communicate (I have already discussed about the art and science of reporting in my previous blogs) them. Clerical errors: How to avoid them? "Gosh, I reported a wrong patient!" Uncommon mistake, but the clinicians easily pick up this blunder. If the clinician reads the report of hand radiograph when he/she has requested CT brain it will be obvious. The clinician might be puzzled to see that none of the findings described by you are seen on the MRI which you have reported, then he/she senses that the radiologist has reported the wrong patient. How to avoid it? 1. Running a system to check that the radiographers put right labels. 2. Double checking the request card and the imaging in question to confirm that we are reporting the right patient (while writing this blog post, I was about to do this mistake!). 3. The most fool proof system is to integrate the voice recognition with PACS. "Right is left, and left is right" Commonly encountered problem, but can have a serious consequences. It is almost like a surgeon operating on a wrong limb. The referring clinicians may not be well versed with right
  5. 5. and left sides of the images, or they may not be able to see the abnormality at all. They all presume what is there in the report unless the abnormality is really big and the clinician knows which is right and left of the image. Fortunately, neurosurgeons are well trained in reading CT and MRI. How to avoid it? 1. Double checking the side whenever we dictate "right", or "left". 2. Train the secretary to alert if they see any confusion in the sides (e.g., the main report may read " There is a tumour in the right parietal lobe...", and in the summary "The features are highly suggestive of a high grade glioma in the left parietal lobe") "I didn't report it. This is not my style" This can happen in a busy department with too many radiologists with few secretaries. When a report comes for final signature, you realize in no time that it is not your report. Every radiologist will have a unique way of reporting. How to avoid it? 1. Check all the reports before signing. 2. Never give authorization to sign your reports to secretaries. "There should have been "NO", why there is no "No"?" Orthopaedic surgeon comes to your office, "I cannot see any fracture in the radial neck, can you please show me?". You look at the image for 10 seconds and tell him, "No, I can't see any either". Then he asks you look at your report, and the report read, "there is evidence of fracture neck of the radius". The "No", which you dictated is missing! How to avoid this?  Repeat "no" twice when dictating. "Where is the report?" Results are lost, results sent to wrong patient or wrong physician, and results arrive too late. They all happen quite frequently in a busy radiology department. How to avoid them?  Prioritise the reporting to avoid delays.  Ask secretaries or radiographers to alert any urgent reporting  Ask secretaries to double check the referring clinicians (especially with same names or surnames). "Mrs X had her uterus and ovaries removed 10 years ago, but you report says the uterus is normal"
  6. 6. This is a common problem when fixed templates are used. You will ask the secretary to change "the liver shows multiple metastases" in "liver heading", and leave the rest as in the template. How to avoid it?  Avoid templates. Treat each patient separately.  When using templates, make sure you have changed the things which are absent (cholecystectomy, hysterectomy, splenectomy, nephrectomy etc).
  7. 7. We are all pre-occupied with something all the time We are humans, and we are prejudiced. As radiologists, we are also prejudiced with our images. Here, I am trying to explore our prejudices (I call them pre-occupations) and try to address how to avoid them, although it is humanly impossible to be completely unoccupied with our prejudices. Pre-occupied with clinical information:  The way we start reading a chest radiograph with history of trauma is so much different from a chest radiograph with history of cough in a smoker. The way we look at a cervical spine radiograph with history of trauma is so much different from looking at a cervical radiograph with history of radiculopathy.  How to avoid it? 1. Look at the images first before looking at the request card. 2. Step outside the request card every time in every patient and look for something which referring clinician has not considered. 3. Keep a mental check list for every part scanned. Pre-occupied with recent diagnosis:  If we made a diagnosis of cortical venous sinus thrombosis (CVT) on CT, then we will be looking for CVT in every brain CT on that day, and following few days. Although it is good habit, the chances are we may ignore other important findings, which we would have picked up if we did not make the diagnosis of CVT.  How to avoid it? 1. Put aside the rare diagnosis which we make on the day. 2. Treat every case as a new case. Pre-occupied with recent mistake:  If we missed rib erosion in a CT chest, which was clearly shown on bone scan, then we start looking at ribs so carefully in every CT chest for following few days that we start consuming too much time to finish our day.  How to avoid it? 1. Develop a quick, but fool proof way, of looking at things where pathology is not frequent. 2. Overcome the recent mistake by discussing with colleague with calm us down, and maybe we can get a tip from the colleague, how to look for them. Pre-occupied with radiology all the time:  As we tend to think of the diagnostic process strictly in terms of imaging, we commit mistakes. When we suggest further examination, it need not be always a radiological examination. In some cases, more clinical history, physical examination, biochemistry or biopsy may be appropriate choice.  How to avoid it? 1. Get out of "radiology box" and think as a clinician. 2. Regular interaction with clinical colleagues 3. Attending clinical-radiological meeting regularly. If there is none, set up one.
  8. 8. Pre-occupied with previous report:  It is complete waste of time if we do not compare the previous scans and report before we put the report. But this may lead to overestimate or underestimate the abnormality. The big trouble is when we have reported the previous scans as well.  How to avoid it? 1. Examine the previous scans without looking at the report first, and then look at the report. 2. Search relevant clinical data between the two scans. Pre-occupied with safe guarding myself:  The patient may have many more imaging or many more radiation, but we want to be safe as far as medicolegal aspect is concerned. This will lead to suggest unnecessary investigations, which can have immense financial and psychological impact on the patient.  How to avoid it? 1. Whenever we tend to suggest some imaging for incidental or undermining findings, we should stop and think if further imaging is really going to change the management at all. 2. Put the patient first Pre-occupied with workload: No doubt, the workload for radiologists has increased several folds and we do not find enough time to inform the findings to the clinicians verbally all the time. But, on some occasions, we should inform the findings verbally to the referring clinicians in case of life threatening events, such as aortic dissection, saddle pulmonary embolism, perforation of abdominal viscera.  How to avoid it? 1. Never forget to pick up the phone to call the team and tell them about the life threatening finding, however obvious it might be 2. Make it a habit to keep all phone numbers with you in your reporting office. Pre-occupied with one's own report/ known diagnosis:  It is quite difficult to get away with the diagnosis which we have already made on the previous occasion. Example: a few rounded low attenuation areas in the liver are reported as simple cysts in the previous report. The same patient undergoes follow-up CT and the size of the lesions have slightly increased. It is definitely not acceptable to report them again as simple cysts, even if the comment has been made in the previous scan report.  How to avoid it? 1. We should come out of the box every time. 2. Careful comparison should be done, and most importantly keep lateral thinking awake all the time. Pre-occupied with one's specialty:  In the era of superspecialization/ subspecialisation, we tend to forget general radiology. AS a musculoskeletal radiologist, I keep looking at bones and muscles in all CT abdomen and pelvis, and pick up lipomas in the muscles, or spondylolysis in
  9. 9. L5, but fail to recognise thrombosis sitting in the common femoral artery, which might change the management.  How to avoid it? 1. Remember, we are general radiologists first, then subspecialty radiologists. 2. Act according to the clinical questions, and then look at your subspecialty subtle findings. Pre-occupied with clinician's specialty:  As soon as the CT is requested by the stroke physician, we start looking for stroke in every CT brain. All hypoattenuating areas will start appearing as infarcts or ischaemic areas, which may be demyelination/ abscess/ metastasis.  How to avoid it? 1. Treat each case separately, and ignore the specialty of the referring clinician. 2. When we complete all the searches, then concentrate on the specialty of the clinician, which may show subtle findings. Pre-occupied with the main finding:  As soon as we see the abnormality we tend to stop looking at other things. The typical example is when the exam going students are made to read a chest radiograph. When they pick up the right lower lobe collapse (a few with great difficulty or prompting), they feel relieved and forget to look at the large metastatic lytic lesion in the left humerus.  How to avoid it? 1. I remember one of the lines (probably from Dr Ravi Ramakantan during REF course during my MD), "Ignore the obvious". 2. Think laterally.
  10. 10. How to identify and rectify the errors? No doubt, most of our errors go unnoticed. It might be due to the fact that many clinicians do not know how to read films, or may not have access to the films. It is financially not feasible to do double blind reading of every film to make it as much fool proof as possible. Hence, we need to develop a method where we can identify the errors and learn from each others' mistakes. 1. Discrepancy meeting: If the department has more than one radiologist, it is worth doing the exercise of discrepancy once a month. The key is keeping anonymity of the reporter, otherwise this may lead to blame culture. In a teaching hospital, the best person to take the lead of discrepancy meeting would be one of the senior residents or a final year post- graduate. All the cases should be collected by the designated person, and the cases should be shown to all the people in the meeting.  This should not be treated like a quiz, or to test juniors or colleagues. The clinical information and all the films available at the time of reporting should be given to the audience. Then discussion should be on the report and subsequent discrepancy on the reporting.  It is worth discussing: 1. Under what circumstance, the discrepancy/error identified? 2. Was further clinical information available at the time of identifying the discrepancy/ error? 3. Was the discrepancy/ error picked with subsequent follow-up imaging? 4. Was the discrepancy/ error on the plain film diagnosed on cross sectional imaging?  The most important bit is to learn from the mistake: 1. To identify why the mistake happened 2. To check if with further clinical information the findings would have picked up 3. To see if review of the previous images would have helped 4. To see if the previous report/ clinical information lead to the bias (covered widely in my previous blog post) Then we need to record the outcome by identifying the severity of the error and grade them. If the mistake/ error found in the meeting is going to change the management, then one should not hesitate to contact the concerned team and convey the findings. Example: A 45 year old man presented with increasing headache. CT scan was reported as bilateral old frontal lobe lacunar infarcts. The patient was referred to neurologist for TIA/ stroke evaluation as the patient was young for stroke/ TIA. Neurologist promptly asked for MRI of the brain. When the neuroradiologist was vetting (checking if the request is appropriate) the request form, he reviewed the CT images, and it was very much evident that the pattern of low attenuation in the both frontal lobes is typical of old frontal lobe contusions secondary to head injury. There was no need of MRI, review of the patient history suggested previous head injury. Hence need for starting lifelong aspirin was avoided. This case was discussed in discrepancy meeting, and the fellow general radiologists re-learnt the basics from a neuroradiologist.
  11. 11. 2. Multidisciplinary team meeting/ clinical-radiological meeting: These are great places for radiologists to learn the beats and pulses of referring clinicians. The radiologist with particular sub-specialty interest should review the images before meeting, and discuss them with the clinicians. The errors/ discrepancies should be conveyed back to the radiologists in the discrepancy meeting. Multidisciplinary meetings typically occur for cancer patients, where the surgeons, oncologists, radiotherapists discuss the diagnosis and management of the patient with radiologist and histopathologist. This is a great learning platform for the radiologists to pick up current trends in the management, and to throw more light in post-operative imaging. With further clinical output, the subtle findings which might have been over looked become important findings, or the same radiological abnormality may look like a different pathology. Clinical-radiological meetings are very educative, and at the same time help to pick the errors/ discrepancies and rectify them. Example: paediatrics-radiology meeting, neurology-radiology meeting, surgery-radiology meeting etc. Example: CT neck of 80 year old smoker was reported as residual tumour in the left laryngeal region. In multidisciplinary meeting, it was evident that the tumour was T1 (based on endoscopic findings and histopathology), and the surgeon has done laser quite recently. The appearances on the CT were not secondary to residual tumour, but from residual inflammation from recent laser. The reason why CT was asked was not to look for larynx, but to look for any nodal metastasis. The message was conveyed back in discrepancy meeting, and the lesson was learnt by all. 3. Subspecialty interest: In a department of few/ many radiologists, it is worth developing one or two subspecialty interest, and start attending courses and conferences in that subspecialty. This will give a great depth to the department. It is not just about interventional radiology or neuroradiology. A department can have a general radiologist with sub- specialty interest in HRCT of the lungs. The subspecialty radiologist will deal with the clinician's second referrals, and discuss the discrepancies. Example: 75 year old smoker presented with breathlessness and weight-loss. CT thorax was reported a mass in the left lower lobe (possible T2/T3 tumour) with N0 M0. The radiologist with special interest in chest imaging was reviewing the images, and found that the mass was not a "mass" but an infarct, and pulmonary embolism in the left lower lobe artery was completely missed. The trauma of undergoing unnecessary biopsy was avoided. In discrepancy meeting, this was discussed, and again, basics are learnt again. Reference:
  12. 12. 1. Vohrah A and Chandy J. Clinical governance: two years experience of reportingdiscrepancy review in radiology. Journal of diagnostic radiography and imaging. 2003 5, 27-32 2. Gunderman RB et al. Managing risk: threat or opportunity? AJR 2005; 185: 43-45