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Diagnostic radiology errors and discrepancies (2).pptx

The document discusses various types of errors that can occur in diagnostic radiology, including perceptual errors, interpretative errors, and biases. It notes that perceptual errors, where an abnormality is simply missed on images, account for around 60-80% of errors. Common missed findings on chest X-rays include small pulmonary nodules. Cognitive and interpretative errors involve seeing an abnormality but misunderstanding its meaning, leading to an incorrect diagnosis. The most frequent types of errors identified in studies include under-reading/missed findings, satisfaction of search errors, and faulty reasoning errors. Human biases like anchoring bias can also influence diagnoses.

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Diagnostic radiology errors and discrepancies • Dr. Vincent Batista Lemaire • Locum Consultant Radiologist • St. Richards Hospital ,University Hospital Sussex Hospitals Trust, NHS . • Chichester , England , UK .
Dedicado a Mi padre Dr. Guarocuya Batista del Villar y mi hermano Dr. Erasmo Vasquez Henriquez.
Diagnostic radiology errors and discrepancies • Dr. Vincent Batista Lemaire • Locum Consultant Radiologist • St. Richards Hospital ,University Hospital Sussex Hospitals Trust, NHS . • Chichester , England , UK .
errors and discrepancies
“perverse report” • Request form CXR • Clinical data : blank • Report: “No evidence of leprosy “
Human Error • Bad publicity from an assumption that perfection is achievable. • Any error or discrepancy must be punished . • The public expects the correct answer all the time . • Tv dramas, media reports describing the error or discrepancy as a scandal . • Unfavourable remarks by politician and lawyers alike. • Medical malpractice claims have been initiated alleging the radiologist’s failure to detect os acromial and os trigonum • Societal and government trend of placing increasing expectation and legal obligation on radiologist. Jury would expect general radiologist to have the same skills as subspecialty radiologist .
Grading or scoring Error • 2014, Royal College of Radiologist (RCR): “grading or scoring errors…was unreliable or subjective…of questionable value, with poor agreement .” • Could fuel a blaming culture; there is danger od deliberate or malicious misuse of error scoring system in the pursuit of personal grievance.
What happens to us Anger Shielding Anxiety Frustration
Is there a problem ? • - Humans will always make errors and radiologist are not different. (RCR ) • - Errors occur in the absence of negligence , hence in the absence of breach of standard of care. • - - Diagnostic errors in medicine causes patient harm , with the rate of missed , incorrect, or delayed diagnoses estimated to be as high as 10-15%. Autopsy have identified major diagnostic discrepancies up to 20% of cases , hence 1 in every 5 patients overall . • Overconfidence …appears to be endemic in medicine. Compared results of diagnosis of ICU patient and autopsy showed that “clinicians who were “completely certain” of the diagnosis antemorten were wrong 40% of the time.” • “errors”: more appropriate to concentrate on “discrepancies” between a report an a retrospective review of a film or outcome . .
Is there a problem ? • Worldwide radiologic examination approximately 1 billion . With a low error rate of 4% this would translate in 40 million radiologist errors per year . • - Some studies showed error rate of 10-15% with 2-20% significant errors. • - Unlike any other medical specialties, apart from pathology, not only do we make errors but we store images to allow retrospective review of our misses.
Is there a problem ? • -Radiologist Leo Henry Garland (1903-1966) pioneer in the study of radiologist error discovered that even skilled and experienced radiologist failed to note important findings on 30% of CXR that were positive for disease and also had 2% of false positive . • - Second reading interpretation performed by experienced abdominal imaging radiologist from Massachusetts General Hospital compared to previous CT abdominopelvic report interpreted by either themselves or colleagues , they disagreed which each other more than 30% of the time –intra-observer- and disagreed with themselves more than 25% of the time –inter observer. • A cancer diagnosis (false-positive) rate of up to 61%has been quoted in screening mammography (Nelson HD et al.) • “…humans are incorrigibly inconsistent in making summary judgments of complex information “. Daniel Kahneman.
Sample of published studies of radiological error: Adrian P Brady • 1.) 1993 , Harvey et al. : Mammography : ca identified on previous studies in 41% when blindly reinterpreted , and 75 % when reviewers were aware subsequence findings. • 2.) 1990,1994, Markus et al. : Barium enema : average observer missed 30% of visible lesions . • 3.)2008, Siewert et al. : Oncologic CT : discordant interpretation in 31-37%, with resultant change in radiological staging in 19%, and change in patient treatment in up to 23%. • 4.) 2007, Briggs et al . : Neuro Ct & MRI: 13% major and 21% minor discrepancy rates (undercalls, overcalls & misinterpretations) when specialist neuroradiologist second reading of studies initially interpreted by general radiologist.
DIAGNOSING UIP
Missed breast cancer • 35% of both interval cancers and screen- detected cancers could be classified as missed. • “missed”: detectable at retrospective review of a previous obtained mammogram that was prospectively reported as showing negative, benign, or probably benign findings d as missed • Leslie R Lamb et al . ; Missed Breast Cancer : Effects of Subconscious Bias and lesion characteristic . RadioGraphics Vol.40 , No 4,Jun 12 2020
Stages in imaging cycle • 1. clinical question ; request of imaging modality ; patient preparation and cooperation . • 2. imaging acquisition and processing . • 3. Radiologist reporting and communication of results.
Types of errors • 1. perceptual • 2. interpretative
Perceptual errors • - All too often , a finding that is readily apparent in retrospect is inexplicably missed. • The consistency of experimental results on radiologist perceptual errors reported worldwide, involving radiologist at all levels of training and experience working in a wide variety of clinical setting and across all imaging modalities , argues convincingly against the idea that radiologist who make errors are simply to blame for being careless , sloppy , or negligent or for underperforming in some way; rather, the phenomenon or radiologist underperception and misperception appears to be an unvarying feature of the extremely complex system in which radiologist operate. (Michael A Bruno et al.)
Perceptual errors • 1. combined sensation in a historic frame of experience and knowledge form a perception of normal or abnormal structure . • 2. perceptual error : those in which and important abnormality is simply not seen on the images , • To be considered a perceptual error, the finding would need to be deemed sufficiently conspicuous and detectable in retrospect by the interpreting radiologist or in the consensus of his or her peers. 60-80% false negative . A few false positive , seen but no present .
CXR most common Perceptual errors Jennifer J Donald and Stuart A Barnard: Common patterns in 558 diagnostic radiology errors
CXR most common Perceptual errors Distribution of missed nodules. Median 16 mm Jennifer J Donald and Stuart A Barnard: Common patterns in 558 diagnostic radiology errors
Cranial imaging most common Perceptual errors Jennifer J Donald and Stuart A Barnard: Common patterns in 558 diagnostic radiology errors
Body CT most common Perceptual errors Jennifer J Donald and Stuart A Barnard: Common patterns in 558 diagnostic radiology errors
Cognitive and interpretative errors • 1. Cognitive : distinguish pathology from non- pathology, and provides either a single differential diagnosis . • 2.Interpretative : 20%-40% • 3.Radiologist may see an abnormality or a normal variant , but they misunderstand its meaning or importance , resulting in an incorrect diagnosis . • 4. False positive : overcalling ; false negative : undercalling
Radiologic Error Classification System 12-category system developed by Kim and Mansfield • Kim and Classification Scheme for Errors in Diagnostic Radiology • Cause of Error Explanation Occurrence (%) • 1.Complacency : An unimportant finding is appreciated but attributed to the wrong • cause –a more serious cause (false-positive finding) 0,9 • 2.Faulty reasoning : A finding is appreciated and interpreted as abnormal • but is attributed to the wrong cause (true-positive finding misclassified) 9.0 • 3.Lack of knowledge : A finding is seen but is attributed to the wrong cause • because of a lack of knowledge on the part of the interpreter 3.0 • 4.Under-reading (missed finding) : A finding is present on the image but is missed 42.0
Radiologic Error Classification System 12-category system developed by Kim and Mansfield • 5.Poor communication : An abnormality is identified and interpreted correctly • but the message does not reach the clinician 0.0 • 6.Technique : A finding is missed because of the limitations of the • examination or technique 2.0 • 7.Prior examination : A finding is missed because of failure to consult prior • radiologic studies or reports 5.0 • 8.History : A finding is missed because of inaccurate or incomplete clinical history 2.0 • 9.Location A : finding is missed because of the location of a lesion outside • the area of interest on an image “tunnel vision”, “scrolling error”, • “innattentional blindness” ,”gorilla in the midst syndrome”. 7.0
Radiologic Error Classification System 12-category system developed by Kim and Mansfield • 10.Satisfaction of search : A finding is missed because of failure to continue to • search for additional abnormalities after the first • abnormality was found , Premature termination 22.0 • 11.Complication : A complication from a procedure 0.5 • 12.Satisfaction of report (alliterative error: “I saw a saw that could out saw any other saw I ever saw”; aliteracion : “tres tristes tigres “) • A finding was missed because of overreliance on the radiology report from a previous examination ; error in one report followed by error in next report” 6 • CONCLUSION: • Delayed diagnoses were not recognized on subsequent radiologic examinations in about one third of the cases. The most common types of error were underreading , satisfaction of search, faulty reasoning, and location of the finding. • Kim YW, Mansfield LT. Fool me twice: delayed diagnoses in radiology with emphasis on perpetuated errors. AJR Am J Roentgenol 2014;202(3):465–470.
Most common biases • A) anchoring bias: locks onto some salient feature too early in the diagnostic process and discounts conflicting or new information gained subsequently . • B) availability bias : recent experience with a disease may inflate the future likehood of its being diagnosed again (conversely, if a disease has not been see for a long time, it may be underdiagnosed). • C) confirmation bias : look for confirmatory evidence to support a diagnostic hypothesis and to ignore evidence that refutes the hypothesis . • D) outcome bias, preference to opt for diagnosis decision that will lead the patient to a better final outcome • E) zebra retreat , self doubt about a remote or unusual diagnosis even though the patient ‘s history and imaging finding support it . • F) frame bias: initially viewing the images prior to reading the clinical details
Human brain • The human brain is a network of about 20 billion neurons – nerve cells – linked by several trillion connections. Not to mention glial cells, which scientists used to think were inactive scaffolding, but increasingly view as an essential part of how the brain works. Our brains give us movement, language, senses, memories, consciousness and personality. We know a lot more about the brain than we used to, but it still seems far too complicated for human understanding.
Human brain • Many of these simple networks occur in the visual system. We used to think that the eye was like a camera, taking a “snapshot” of the outside world that was stored in the brain like a photo stuck in an album. It uses a lens to focus an image on to the retina at the back of the eye, which functions a bit like a roll of film – or, in today’s digital cameras, a charge- coupled device, storing an image pixel by pixel. But we now know that when the retina sends information to the brain’s visual cortex, the similarity to a camera ends. • Although we get a strong impression that what we are seeing is “out there” in front of us, what determines that perception resides inside our own heads. The brain decomposes images into simple pieces, works out what they are, “labels” them with that information, and reassembles them. • An effective way to infer how something functions is to see what it does when it goes wrong. It may be hard to understand a bridge while it stays up, but you can learn a lot about strength of materials when it collapses.
Muller-Lyer illusion
Visual and thinking illusion
checker shadow illusion
Most common illusions of sensations in Radiology :Mach bands and background effects
Selective looking • It is a well-known phenomenon that we do not notice anything happening in our surroundings while being absorbed in the inspection of something; focusing our attention on a certain object may happen to such an extent that we cannot perceive other objects placed in the peripheral parts of our visual field, although the light rays they emit arrive completely at the visual sphere of the cerebral cortex.'' Rezso« Ba¨lint 1907 (translated in Husain and Stein 1988, page 91)
Gorilla in the mist syndrome • https://www.youtube.com/watch?v=wdVXco6 YDgg • 48 times the size of the nodules. • 83% of radiologist did not see the gorilla.
Selective looking : UNDER-READING (MISSED FINDING ) 2014 2015 2016
UNDER-READING (MISSED FINDING ) F/U lung lesion ; missed oesophageal cancer.
Selective looking : UNDER-READING (MISSED FINDING ) Acute appendicitis ; missed oesophageal cancer.
Selective looking : UNDER-READING (MISSED FINDING ) Acute appendicitis ; missed oesophageal cancer.
Selective looking : UNDER-READING (MISSED FINDING ) Ca prostate ; missed tiny met in the R ischial tuberosity
Selective looking : UNDER-READING (MISSED FINDING )
UNDER-READING (MISSED FINDING ) Pellegrini –Stieda: window setting and zoom
UNDER-READING (MISSED FINDING ) Sleeve patellar fracture: window and magnification .
UNDER-READING (MISSED FINDING ) Subchondral lesion : window setting
UNDER-READING (MISSED FINDING ) Window setting
UNDER-READING (MISSED FINDING ) 3 days before Cardiac arrest Always compared with previous available exams
UNDER-READING (MISSED FINDING ) Window setting : background
UNDER-READING (MISSED FINDING )
UNDER-READING (MISSED FINDING ) Check the veins and nodes
UNDER-READING (MISSED FINDING ) Window setting : background liver window width and level for pancreas
UNDER-READING (MISSED FINDING ) CHANGE WINDOW SETTING (BACKGROUND): NEVER REPORT A VENOGRAM OR ANGIOGRAM WITHOUT A BASE LINE CT OR MRI
UNDER-READING (MISSED FINDING ) Apart of checking the appendix check the terminal ileum for skip lesions
UNDER-READING (MISSED FINDING ) Tiny RCC
UNDER-READING (MISSED FINDING ) Look very carefully when only one kidney is left after RCC
UNDER-READING (MISSED FINDING ) ?cyst
UNDER-READING (MISSED FINDING ) No everything is a cyst
UNDER-READING (MISSED FINDING ) Review skull base, mandible , paranasal sinuses , orbits …
UNDER-READING (MISSED FINDING )? Reported normal.
UNDER-READING (MISSED FINDING )? Was quite normal. 
SATISFACTION OF SEARCH Check the arteries
SATISFACTION OF SEARCH
SATISFACTION OF SEARCH Peritoneal nodules ; missed PE
SATISFACTION OF SEARCH Prostate ca , missed rectal cancer.
SATISFACTION OF SEARCH R renal calculus ; missed peritoneal nodules.
SATISFACTION OF SEARCH Shoulder arthrography ; missed lung nodule
SATISFACTION OF SEARCH Ground-glass infiltrates, missed ribs fractures
SATISFACTION OF SEARCH Lung tumour; missed PE in middle lobe and rib fracture
FAULTY REASONING Apart of meningioma there are dural calcifications and osteomas
FAULTY REASONING
FAULTY REASONING Calcified pseudotumor of the neuroaxis
FAULTY REASONING Active Paget , melanoma metastasis : never r/o metastasis .
FAULTY REASONING Diaphragmatic Slip (muscular bundles that cause hepatic invagination in a patient with stomach antral ca )
FAULTY REASONING Focal lesion in L1 with subtle low T1 signal and high signal on T2/STIR: H/O thyroid ca ; Possible atypical haemangioma but f/u to r/o met : is a fat poor haemangioma .
FAULTY REASONING :20 Y OLD FEMALE CARDIAC AREST AFTER ANAPHILAXIS CT T2W
FAULTY REASONING :HYPOXIC ISCHEMIC ENCEPHALOPATYY 20 years 10 years T2W
FAULTY REASONING :HYPOXIC ISCHEMIC ENCEPHALOPATYY 20 years 12 years DWI
FAULTY REASONING :HYPOXIC ISCHEMIC ENCEPHALOPATYY ADC
Diaphragmatic slip
ABNORMALITIES OUTSIDE AREA OF INTEREST (BUT VISIBLE) Mass and lymphadenopathy : lymphoma , sarcoma , fibrous histicocytoma Diagnostic : Castleman Disease: angio-follicular lymph node hyperplasia
ABNORMALITIES OUTSIDE AREA OF INTEREST (BUT VISIBLE) RCC seen in the localizer for lumbar spine : look to all localiser
ABNORMALITIES OUTSIDE AREA OF INTEREST (BUT VISIBLE) 2018 2019
ABNORMALITIES OUTSIDE AREA OF INTEREST (BUT VISIBLE) 2020
SATISFACTION OF REPORT:ALLITERATIVE REASONING index Perforation and f/u
SATISFACTION OF REPORT:ALLITERATIVE REASONING X 2 X 4 X 7 Always check again
SATISFACTION OF REPORT:ALLITERATIVE REASONING
SATISFACTION OF REPORT:ALLITERATIVE REASONING Patient with breast cancer : looks for mets: missed small meningioma , satisfaction of search and alliaterative reasoning : 2013, 2014, 2016, 2016, 2017, 2019 bingo 2020!
INACCURATE OR INCOMPLETE CLINICAL HISTORY Breast mets: I did not check previous CT 4 years before : sarcoid
CORRECT REPORT FAILING TO REACH REFERRING CLINICIAN 2016 2016 2017 Inspissated bile Wall-thickened Tumour vs. abscess Significant finding overlooked because was no in the conclusion Referred for GB polyp
History 82 y/o F : epigastric pain , weight loss , dysphagia : recent OGD normal, US normal. CT: no sinister but has oesophageal cancer at OGJ : normal OGD !!
Individual performance
Individual performance • No follow Gaussian (normal) distribution but Paretian (power) distribution where most performers are below “average”, and thus less productive and more likely to make mistakes than the super-performers.
Factors/causes of errors • Technique or Image acquisitions errors : the lesion is hidden due to limited or suboptimal scanning . • Perceptual /cognitive /interpretative • External causes and communications
Perceptual /cognitive /interpretative • Training , Experience, Intellect • Concentration ,Perceptual skill • Fatigue, illness , mood • Shortcuts: viewing one place • Failing to optimized tools : window setting • Attempting to interpret grossly poor quality images. • Failure to compare to all previous images or pertinent studies available
Improvement 1 • Look at the image as it belong to your best friend. • Training • Attending courses • Peer review • Discrepancy ,MDT and morbimortality meetings . • Share diagnostic mistakes • Perform our own interpretation before reading the previous radiology report to avoid alliterative errors • Pay attention to the first and last image , to the scout view or localizer , at the corners .
External causes and communications. • Heavy workloads : ER , large volume of cases , fast turnaround , many study in short period, numerous body part. • Distractions : noise, chat , phone calls (increased 12% like hood of error).Internet , whatsapp , mails . • Overly rapid pace. • Failure to review the voice recognition ; copy-paste errors , template. • Failure to communicate regarding unexpected important finding. • Failure of PACS server to retrieve prior exam . • Lack of immediate online diagnostic references resources. • Tele radiology services
More improvements • Quality management (QI: Quality Improvement )activities: Events and Learning meetings , audits, continuing education, appraisal . • Check-list : reduce errors of omission in a wide variety of fields including aviation, critical care medicine and presumably radiology. Widely used on PET-CT; remind radiologist to take a second look at certain aspects , areas , and features of the images.
More improvements • Structured report; standardizing, for cancer, measurements . Thyroid US , mammography BI-RADS , Prostate PI-RADS , CT colonography Classification ; etc improving communication . • Double reading : widely used in mammography reading . • PET-CT, computer-aided detection and Artificial intelligence (AI): highlight neglected areas in mamography, lung nodule detection , Ct colonography . • Improving individual physician factors.
PET-CT
AI
Computer assisted solution
Computer assisted solution
Learning from discrepancy meeting • 1. A reporting discrepancy occurs when a retrospective review, or subsequent information about patient outcome, leads to an opinion different from that expressed in the original report. • Acceptance of the concept of necessary fallibility needs to be encourage; public education can help . Fortunately , many errors identified by retrospective reviews are of little or no significance to patient ; conversely , some significant errors are never discovered (A.Brady)
Hindsight bias • “Tendency for people with knowledge of the actual outcome of an event to believe falsely that they would have predicted the outcome “(Berlin , L)
Duty of candour
Experts • One who knows more and more about less and less until he knows absolutely everything about nothing .
CUOTE • IT IS SAID, THE WISE LEARN FROM THE MISTAKES OF OTHERS, THE SMART LEARN FROM THEIR OWN MISTAKES, AND THE FOOLISH LEARN FROM NEITHER.
REFERENCES • • Daniel Kahneman. Thinking, Fast and Slow. Farrar, Straus and Giroux , ISBN 978-0-347-27563-1; 2013. • Michael A Bruno et al . Understanding and Confronting Our Mistakes: The Epidemiology of Error in Radiology and Strategies for Error reduction .RadioGraphics 2015; 35:1668-1676. • Common patterns in 558 diagnostic radiology errors. Jennifer J Donald and Stuart A Barnard. Journal of Medical Imaging and Radiation Oncology 56 (2012)173-178 • Adrian P Brady .Error and discrepancy in radiology: inevitable or avoidable?. Insights Imaging (2017)8: 171-182 • Stuart E Mirvis. Toward decreasing diagnostic errors. The Journal of Practical Medical Imaging and Management . • Young W Kim and Liem T Mansfield. Fool Me Twice: Delayed Diagnoses in Radiology With Emphasis on Perpetual Errors. AJR 2014; 202: 465-470 • Adrian Brady et al. Discrepancy and Error in Radiology: Concepts, Causes and Consequences . Ulster Med J 2012; 81(1): 3-9 • The RCR : REAL , Radiology Events and Learning . real@rcr.ac.uk • Clinical radiology. The RCR : Standards for Learning from Discrepancy Meetings. www.rcr.ac.uk • Christopher E. Bickle et al . Now You see It , Now you Don’t: Visual Illusions in Radiology . RadioGraphics 2013; 33:2087-2102. •
85y/o female
Swirl sign 85 y/o woman :Lobar haemorrhage . Almost no surrounding edema. The basal ganglia are spared. Low density in the core In keeping with active bleeding . Severe edema effacing the sulci and sylvian fissure.
Cheshire Hall Medical Centre

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Diagnostic radiology errors and discrepancies (2).pptx

  • 1.
    Diagnostic radiology errorsand discrepancies • Dr. Vincent Batista Lemaire • Locum Consultant Radiologist • St. Richards Hospital ,University Hospital Sussex Hospitals Trust, NHS . • Chichester , England , UK .
  • 2.
    Dedicado a Mipadre Dr. Guarocuya Batista del Villar y mi hermano Dr. Erasmo Vasquez Henriquez.
  • 3.
    Diagnostic radiology errorsand discrepancies • Dr. Vincent Batista Lemaire • Locum Consultant Radiologist • St. Richards Hospital ,University Hospital Sussex Hospitals Trust, NHS . • Chichester , England , UK .
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    “perverse report” • Requestform CXR • Clinical data : blank • Report: “No evidence of leprosy “
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    Human Error • Badpublicity from an assumption that perfection is achievable. • Any error or discrepancy must be punished . • The public expects the correct answer all the time . • Tv dramas, media reports describing the error or discrepancy as a scandal . • Unfavourable remarks by politician and lawyers alike. • Medical malpractice claims have been initiated alleging the radiologist’s failure to detect os acromial and os trigonum • Societal and government trend of placing increasing expectation and legal obligation on radiologist. Jury would expect general radiologist to have the same skills as subspecialty radiologist .
  • 7.
    Grading or scoringError • 2014, Royal College of Radiologist (RCR): “grading or scoring errors…was unreliable or subjective…of questionable value, with poor agreement .” • Could fuel a blaming culture; there is danger od deliberate or malicious misuse of error scoring system in the pursuit of personal grievance.
  • 8.
    What happens tous Anger Shielding Anxiety Frustration
  • 9.
    Is there aproblem ? • - Humans will always make errors and radiologist are not different. (RCR ) • - Errors occur in the absence of negligence , hence in the absence of breach of standard of care. • - - Diagnostic errors in medicine causes patient harm , with the rate of missed , incorrect, or delayed diagnoses estimated to be as high as 10-15%. Autopsy have identified major diagnostic discrepancies up to 20% of cases , hence 1 in every 5 patients overall . • Overconfidence …appears to be endemic in medicine. Compared results of diagnosis of ICU patient and autopsy showed that “clinicians who were “completely certain” of the diagnosis antemorten were wrong 40% of the time.” • “errors”: more appropriate to concentrate on “discrepancies” between a report an a retrospective review of a film or outcome . .
  • 10.
    Is there aproblem ? • Worldwide radiologic examination approximately 1 billion . With a low error rate of 4% this would translate in 40 million radiologist errors per year . • - Some studies showed error rate of 10-15% with 2-20% significant errors. • - Unlike any other medical specialties, apart from pathology, not only do we make errors but we store images to allow retrospective review of our misses.
  • 11.
    Is there aproblem ? • -Radiologist Leo Henry Garland (1903-1966) pioneer in the study of radiologist error discovered that even skilled and experienced radiologist failed to note important findings on 30% of CXR that were positive for disease and also had 2% of false positive . • - Second reading interpretation performed by experienced abdominal imaging radiologist from Massachusetts General Hospital compared to previous CT abdominopelvic report interpreted by either themselves or colleagues , they disagreed which each other more than 30% of the time –intra-observer- and disagreed with themselves more than 25% of the time –inter observer. • A cancer diagnosis (false-positive) rate of up to 61%has been quoted in screening mammography (Nelson HD et al.) • “…humans are incorrigibly inconsistent in making summary judgments of complex information “. Daniel Kahneman.
  • 12.
    Sample of publishedstudies of radiological error: Adrian P Brady • 1.) 1993 , Harvey et al. : Mammography : ca identified on previous studies in 41% when blindly reinterpreted , and 75 % when reviewers were aware subsequence findings. • 2.) 1990,1994, Markus et al. : Barium enema : average observer missed 30% of visible lesions . • 3.)2008, Siewert et al. : Oncologic CT : discordant interpretation in 31-37%, with resultant change in radiological staging in 19%, and change in patient treatment in up to 23%. • 4.) 2007, Briggs et al . : Neuro Ct & MRI: 13% major and 21% minor discrepancy rates (undercalls, overcalls & misinterpretations) when specialist neuroradiologist second reading of studies initially interpreted by general radiologist.
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    Missed breast cancer •35% of both interval cancers and screen- detected cancers could be classified as missed. • “missed”: detectable at retrospective review of a previous obtained mammogram that was prospectively reported as showing negative, benign, or probably benign findings d as missed • Leslie R Lamb et al . ; Missed Breast Cancer : Effects of Subconscious Bias and lesion characteristic . RadioGraphics Vol.40 , No 4,Jun 12 2020
  • 15.
    Stages in imagingcycle • 1. clinical question ; request of imaging modality ; patient preparation and cooperation . • 2. imaging acquisition and processing . • 3. Radiologist reporting and communication of results.
  • 16.
    Types of errors •1. perceptual • 2. interpretative
  • 17.
    Perceptual errors • -All too often , a finding that is readily apparent in retrospect is inexplicably missed. • The consistency of experimental results on radiologist perceptual errors reported worldwide, involving radiologist at all levels of training and experience working in a wide variety of clinical setting and across all imaging modalities , argues convincingly against the idea that radiologist who make errors are simply to blame for being careless , sloppy , or negligent or for underperforming in some way; rather, the phenomenon or radiologist underperception and misperception appears to be an unvarying feature of the extremely complex system in which radiologist operate. (Michael A Bruno et al.)
  • 18.
    Perceptual errors • 1.combined sensation in a historic frame of experience and knowledge form a perception of normal or abnormal structure . • 2. perceptual error : those in which and important abnormality is simply not seen on the images , • To be considered a perceptual error, the finding would need to be deemed sufficiently conspicuous and detectable in retrospect by the interpreting radiologist or in the consensus of his or her peers. 60-80% false negative . A few false positive , seen but no present .
  • 19.
    CXR most commonPerceptual errors Jennifer J Donald and Stuart A Barnard: Common patterns in 558 diagnostic radiology errors
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    CXR most commonPerceptual errors Distribution of missed nodules. Median 16 mm Jennifer J Donald and Stuart A Barnard: Common patterns in 558 diagnostic radiology errors
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    Cranial imaging mostcommon Perceptual errors Jennifer J Donald and Stuart A Barnard: Common patterns in 558 diagnostic radiology errors
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    Body CT mostcommon Perceptual errors Jennifer J Donald and Stuart A Barnard: Common patterns in 558 diagnostic radiology errors
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    Cognitive and interpretativeerrors • 1. Cognitive : distinguish pathology from non- pathology, and provides either a single differential diagnosis . • 2.Interpretative : 20%-40% • 3.Radiologist may see an abnormality or a normal variant , but they misunderstand its meaning or importance , resulting in an incorrect diagnosis . • 4. False positive : overcalling ; false negative : undercalling
  • 24.
    Radiologic Error ClassificationSystem 12-category system developed by Kim and Mansfield • Kim and Classification Scheme for Errors in Diagnostic Radiology • Cause of Error Explanation Occurrence (%) • 1.Complacency : An unimportant finding is appreciated but attributed to the wrong • cause –a more serious cause (false-positive finding) 0,9 • 2.Faulty reasoning : A finding is appreciated and interpreted as abnormal • but is attributed to the wrong cause (true-positive finding misclassified) 9.0 • 3.Lack of knowledge : A finding is seen but is attributed to the wrong cause • because of a lack of knowledge on the part of the interpreter 3.0 • 4.Under-reading (missed finding) : A finding is present on the image but is missed 42.0
  • 25.
    Radiologic Error ClassificationSystem 12-category system developed by Kim and Mansfield • 5.Poor communication : An abnormality is identified and interpreted correctly • but the message does not reach the clinician 0.0 • 6.Technique : A finding is missed because of the limitations of the • examination or technique 2.0 • 7.Prior examination : A finding is missed because of failure to consult prior • radiologic studies or reports 5.0 • 8.History : A finding is missed because of inaccurate or incomplete clinical history 2.0 • 9.Location A : finding is missed because of the location of a lesion outside • the area of interest on an image “tunnel vision”, “scrolling error”, • “innattentional blindness” ,”gorilla in the midst syndrome”. 7.0
  • 26.
    Radiologic Error ClassificationSystem 12-category system developed by Kim and Mansfield • 10.Satisfaction of search : A finding is missed because of failure to continue to • search for additional abnormalities after the first • abnormality was found , Premature termination 22.0 • 11.Complication : A complication from a procedure 0.5 • 12.Satisfaction of report (alliterative error: “I saw a saw that could out saw any other saw I ever saw”; aliteracion : “tres tristes tigres “) • A finding was missed because of overreliance on the radiology report from a previous examination ; error in one report followed by error in next report” 6 • CONCLUSION: • Delayed diagnoses were not recognized on subsequent radiologic examinations in about one third of the cases. The most common types of error were underreading , satisfaction of search, faulty reasoning, and location of the finding. • Kim YW, Mansfield LT. Fool me twice: delayed diagnoses in radiology with emphasis on perpetuated errors. AJR Am J Roentgenol 2014;202(3):465–470.
  • 27.
    Most common biases •A) anchoring bias: locks onto some salient feature too early in the diagnostic process and discounts conflicting or new information gained subsequently . • B) availability bias : recent experience with a disease may inflate the future likehood of its being diagnosed again (conversely, if a disease has not been see for a long time, it may be underdiagnosed). • C) confirmation bias : look for confirmatory evidence to support a diagnostic hypothesis and to ignore evidence that refutes the hypothesis . • D) outcome bias, preference to opt for diagnosis decision that will lead the patient to a better final outcome • E) zebra retreat , self doubt about a remote or unusual diagnosis even though the patient ‘s history and imaging finding support it . • F) frame bias: initially viewing the images prior to reading the clinical details
  • 28.
    Human brain • Thehuman brain is a network of about 20 billion neurons – nerve cells – linked by several trillion connections. Not to mention glial cells, which scientists used to think were inactive scaffolding, but increasingly view as an essential part of how the brain works. Our brains give us movement, language, senses, memories, consciousness and personality. We know a lot more about the brain than we used to, but it still seems far too complicated for human understanding.
  • 29.
    Human brain • Manyof these simple networks occur in the visual system. We used to think that the eye was like a camera, taking a “snapshot” of the outside world that was stored in the brain like a photo stuck in an album. It uses a lens to focus an image on to the retina at the back of the eye, which functions a bit like a roll of film – or, in today’s digital cameras, a charge- coupled device, storing an image pixel by pixel. But we now know that when the retina sends information to the brain’s visual cortex, the similarity to a camera ends. • Although we get a strong impression that what we are seeing is “out there” in front of us, what determines that perception resides inside our own heads. The brain decomposes images into simple pieces, works out what they are, “labels” them with that information, and reassembles them. • An effective way to infer how something functions is to see what it does when it goes wrong. It may be hard to understand a bridge while it stays up, but you can learn a lot about strength of materials when it collapses.
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    Most common illusionsof sensations in Radiology :Mach bands and background effects
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    Selective looking • Itis a well-known phenomenon that we do not notice anything happening in our surroundings while being absorbed in the inspection of something; focusing our attention on a certain object may happen to such an extent that we cannot perceive other objects placed in the peripheral parts of our visual field, although the light rays they emit arrive completely at the visual sphere of the cerebral cortex.'' Rezso« Ba¨lint 1907 (translated in Husain and Stein 1988, page 91)
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    Gorilla in themist syndrome • https://www.youtube.com/watch?v=wdVXco6 YDgg • 48 times the size of the nodules. • 83% of radiologist did not see the gorilla.
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    Selective looking : UNDER-READING(MISSED FINDING ) 2014 2015 2016
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    UNDER-READING (MISSED FINDING) F/U lung lesion ; missed oesophageal cancer.
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    Selective looking : UNDER-READING(MISSED FINDING ) Acute appendicitis ; missed oesophageal cancer.
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    Selective looking : UNDER-READING(MISSED FINDING ) Acute appendicitis ; missed oesophageal cancer.
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    Selective looking : UNDER-READING(MISSED FINDING ) Ca prostate ; missed tiny met in the R ischial tuberosity
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    UNDER-READING (MISSED FINDING) Pellegrini –Stieda: window setting and zoom
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    UNDER-READING (MISSED FINDING) Sleeve patellar fracture: window and magnification .
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    UNDER-READING (MISSED FINDING) Subchondral lesion : window setting
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    UNDER-READING (MISSED FINDING) 3 days before Cardiac arrest Always compared with previous available exams
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    UNDER-READING (MISSED FINDING) Window setting : background
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    UNDER-READING (MISSED FINDING) Check the veins and nodes
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    UNDER-READING (MISSED FINDING) Window setting : background liver window width and level for pancreas
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    UNDER-READING (MISSED FINDING) CHANGE WINDOW SETTING (BACKGROUND): NEVER REPORT A VENOGRAM OR ANGIOGRAM WITHOUT A BASE LINE CT OR MRI
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    UNDER-READING (MISSED FINDING) Apart of checking the appendix check the terminal ileum for skip lesions
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    UNDER-READING (MISSED FINDING) Look very carefully when only one kidney is left after RCC
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    UNDER-READING (MISSED FINDING) No everything is a cyst
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    UNDER-READING (MISSED FINDING) Review skull base, mandible , paranasal sinuses , orbits …
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    UNDER-READING (MISSED FINDING)? Reported normal.
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    UNDER-READING (MISSED FINDING)? Was quite normal. 
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    SATISFACTION OF SEARCH Prostateca , missed rectal cancer.
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    SATISFACTION OF SEARCH Rrenal calculus ; missed peritoneal nodules.
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    SATISFACTION OF SEARCH Shoulderarthrography ; missed lung nodule
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    SATISFACTION OF SEARCH Ground-glassinfiltrates, missed ribs fractures
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    SATISFACTION OF SEARCH Lungtumour; missed PE in middle lobe and rib fracture
  • 68.
    FAULTY REASONING Apart ofmeningioma there are dural calcifications and osteomas
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  • 71.
    FAULTY REASONING Active Paget, melanoma metastasis : never r/o metastasis .
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    FAULTY REASONING Diaphragmatic Slip(muscular bundles that cause hepatic invagination in a patient with stomach antral ca )
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    FAULTY REASONING Focal lesionin L1 with subtle low T1 signal and high signal on T2/STIR: H/O thyroid ca ; Possible atypical haemangioma but f/u to r/o met : is a fat poor haemangioma .
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    FAULTY REASONING :20Y OLD FEMALE CARDIAC AREST AFTER ANAPHILAXIS CT T2W
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    FAULTY REASONING :HYPOXIC ISCHEMICENCEPHALOPATYY 20 years 10 years T2W
  • 76.
    FAULTY REASONING :HYPOXIC ISCHEMICENCEPHALOPATYY 20 years 12 years DWI
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  • 78.
  • 79.
    ABNORMALITIES OUTSIDE AREAOF INTEREST (BUT VISIBLE) Mass and lymphadenopathy : lymphoma , sarcoma , fibrous histicocytoma Diagnostic : Castleman Disease: angio-follicular lymph node hyperplasia
  • 80.
    ABNORMALITIES OUTSIDE AREAOF INTEREST (BUT VISIBLE) RCC seen in the localizer for lumbar spine : look to all localiser
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    ABNORMALITIES OUTSIDE AREAOF INTEREST (BUT VISIBLE) 2018 2019
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    ABNORMALITIES OUTSIDE AREAOF INTEREST (BUT VISIBLE) 2020
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  • 86.
    SATISFACTION OF REPORT:ALLITERATIVE REASONING Patientwith breast cancer : looks for mets: missed small meningioma , satisfaction of search and alliaterative reasoning : 2013, 2014, 2016, 2016, 2017, 2019 bingo 2020!
  • 87.
    INACCURATE OR INCOMPLETECLINICAL HISTORY Breast mets: I did not check previous CT 4 years before : sarcoid
  • 88.
    CORRECT REPORT FAILINGTO REACH REFERRING CLINICIAN 2016 2016 2017 Inspissated bile Wall-thickened Tumour vs. abscess Significant finding overlooked because was no in the conclusion Referred for GB polyp
  • 89.
    History 82 y/o F: epigastric pain , weight loss , dysphagia : recent OGD normal, US normal. CT: no sinister but has oesophageal cancer at OGJ : normal OGD !!
  • 90.
  • 91.
    Individual performance • Nofollow Gaussian (normal) distribution but Paretian (power) distribution where most performers are below “average”, and thus less productive and more likely to make mistakes than the super-performers.
  • 92.
    Factors/causes of errors •Technique or Image acquisitions errors : the lesion is hidden due to limited or suboptimal scanning . • Perceptual /cognitive /interpretative • External causes and communications
  • 93.
    Perceptual /cognitive /interpretative •Training , Experience, Intellect • Concentration ,Perceptual skill • Fatigue, illness , mood • Shortcuts: viewing one place • Failing to optimized tools : window setting • Attempting to interpret grossly poor quality images. • Failure to compare to all previous images or pertinent studies available
  • 94.
    Improvement 1 • Lookat the image as it belong to your best friend. • Training • Attending courses • Peer review • Discrepancy ,MDT and morbimortality meetings . • Share diagnostic mistakes • Perform our own interpretation before reading the previous radiology report to avoid alliterative errors • Pay attention to the first and last image , to the scout view or localizer , at the corners .
  • 95.
    External causes andcommunications. • Heavy workloads : ER , large volume of cases , fast turnaround , many study in short period, numerous body part. • Distractions : noise, chat , phone calls (increased 12% like hood of error).Internet , whatsapp , mails . • Overly rapid pace. • Failure to review the voice recognition ; copy-paste errors , template. • Failure to communicate regarding unexpected important finding. • Failure of PACS server to retrieve prior exam . • Lack of immediate online diagnostic references resources. • Tele radiology services
  • 96.
    More improvements • Qualitymanagement (QI: Quality Improvement )activities: Events and Learning meetings , audits, continuing education, appraisal . • Check-list : reduce errors of omission in a wide variety of fields including aviation, critical care medicine and presumably radiology. Widely used on PET-CT; remind radiologist to take a second look at certain aspects , areas , and features of the images.
  • 97.
    More improvements • Structuredreport; standardizing, for cancer, measurements . Thyroid US , mammography BI-RADS , Prostate PI-RADS , CT colonography Classification ; etc improving communication . • Double reading : widely used in mammography reading . • PET-CT, computer-aided detection and Artificial intelligence (AI): highlight neglected areas in mamography, lung nodule detection , Ct colonography . • Improving individual physician factors.
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  • 100.
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  • 102.
    Learning from discrepancymeeting • 1. A reporting discrepancy occurs when a retrospective review, or subsequent information about patient outcome, leads to an opinion different from that expressed in the original report. • Acceptance of the concept of necessary fallibility needs to be encourage; public education can help . Fortunately , many errors identified by retrospective reviews are of little or no significance to patient ; conversely , some significant errors are never discovered (A.Brady)
  • 103.
    Hindsight bias • “Tendencyfor people with knowledge of the actual outcome of an event to believe falsely that they would have predicted the outcome “(Berlin , L)
  • 104.
  • 105.
    Experts • One whoknows more and more about less and less until he knows absolutely everything about nothing .
  • 106.
    CUOTE • IT ISSAID, THE WISE LEARN FROM THE MISTAKES OF OTHERS, THE SMART LEARN FROM THEIR OWN MISTAKES, AND THE FOOLISH LEARN FROM NEITHER.
  • 107.
    REFERENCES • • Daniel Kahneman.Thinking, Fast and Slow. Farrar, Straus and Giroux , ISBN 978-0-347-27563-1; 2013. • Michael A Bruno et al . Understanding and Confronting Our Mistakes: The Epidemiology of Error in Radiology and Strategies for Error reduction .RadioGraphics 2015; 35:1668-1676. • Common patterns in 558 diagnostic radiology errors. Jennifer J Donald and Stuart A Barnard. Journal of Medical Imaging and Radiation Oncology 56 (2012)173-178 • Adrian P Brady .Error and discrepancy in radiology: inevitable or avoidable?. Insights Imaging (2017)8: 171-182 • Stuart E Mirvis. Toward decreasing diagnostic errors. The Journal of Practical Medical Imaging and Management . • Young W Kim and Liem T Mansfield. Fool Me Twice: Delayed Diagnoses in Radiology With Emphasis on Perpetual Errors. AJR 2014; 202: 465-470 • Adrian Brady et al. Discrepancy and Error in Radiology: Concepts, Causes and Consequences . Ulster Med J 2012; 81(1): 3-9 • The RCR : REAL , Radiology Events and Learning . real@rcr.ac.uk • Clinical radiology. The RCR : Standards for Learning from Discrepancy Meetings. www.rcr.ac.uk • Christopher E. Bickle et al . Now You see It , Now you Don’t: Visual Illusions in Radiology . RadioGraphics 2013; 33:2087-2102. •
  • 108.
  • 109.
    Swirl sign 85 y/owoman :Lobar haemorrhage . Almost no surrounding edema. The basal ganglia are spared. Low density in the core In keeping with active bleeding . Severe edema effacing the sulci and sylvian fissure.
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