Interpretive Error in Radiology.

OBJECTIVE: Although imaging technology has advanced significantly since the work of Garland in 1949, interpretive error rates remain unchanged. In addition to patient harm, interpretive errors are a major cause of litigation and distress to radiologists. In this article, we discuss the mechanics involved in searching an image, categorize omission errors, and discuss factors influencing diagnostic accuracy. Potential individual- and system-based solutions to mitigate or eliminate errors are also discussed. CONCLUSION: Radiologists use visual detection, pattern recognition, memory, and cognitive reasoning to synthesize final interpretations of radiologic studies. This synthesis is performed in an environment in which there are numerous extrinsic distractors, increasing workloads and fatigue. Given the ultimately human task of perception, some degree of error is likely inevitable even with experienced observers. However, an understanding of the causes of interpretive errors can help in the development of tools to mitigate errors and improve patient safety.

Systemic Error in Radiology.

OBJECTIVE: Interpretive errors in diagnostic imaging result in significant patient morbidity and mortality, but the importance of errors and process failures in the imaging cycle other than during image interpretation is underappreciated. In this article, we describe these errors and potential solutions, providing a framework to improve patient safety and understand the changing roles of radiologists beyond image interpretation. CONCLUSION: For comprehensive improvements to health care delivery, other failures in the cycle besides diagnostic interpretive error-such as ordering inappropriate studies, PACS failures, and a lack of accurate clinician contact information (with resultant communication failure)-should be recognized as contributors to patient harm because they lead to wasted resources and delayed care. By taking ownership of the entire imaging cycle, radiologists can increase their net worth to patient care and cement their roles as experts in the effective, evidence-based use of imaging technologies.

Diagnosis-related Groups and Hospital Inpatient Federal Reimbursement.

To understand the complex system of reimbursement for health care services, it is helpful to have a working knowledge of the historic context of diagnosis-related groups (DRGs), as well as their utility and increasing relevance. Congress implemented the DRG system in 1983 in response to rapidly increasing health care costs. The DRG system was designed to control hospital reimbursements by replacing retrospective payments with prospective payments for hospital charges. This article explains how these payments are calculated. Every inpatient admission is classified into one of several hundred DRGs that are based on the diagnosis, complications, and comorbidities. The Centers for Medicare & Medicaid Services (CMS) assigns each DRG a weight that the CMS uses in conjunction with hospital-specific data to determine reimbursement. A population's DRGs represent the resources needed to treat the medical disorders of that population. Hospital administrators use this information to budget and plan for the future. The Affordable Care Act and other recent legislation affect medical reimbursement by altering the DRG system. Radiologic procedures in particular are affected. This legislation will give DRGs an even larger role in determining reimbursements in the coming years.

Use of an automated critical test result management system: effect on message delivery time.

Using an automated CTRM system in a radiology department leads to improved delivery of critical test results. Although a significant proportion of the improvement stems from experience, other factors likely contribute (eg, administrative support and acceptance by the medical staff). Longitudinal message documentation data was collected from 8 facilities. Data was evaluated to exclude the null hypothesis (absence of a relationship). CTRM experience (measured in days) was correlated with message delivery time (measured in hours). The goal was to evaluate the relationship between duration of experience and reduction in notification turnaround time (TAT).The inverse relationship of duration of experience with reduced TAT was highly significant, independent of other factors, even though experience only accounted for 25% of the improvement.

Communication errors in radiology - Pitfalls and how to avoid them.

Communication failures are a common cause of patient harm and malpractice claims against radiologists. In addition to overt communication breakdowns among providers, it is also important to address the quality of communication to optimize patient outcomes. In this review, we describe common communication failures and potential solutions providing a framework for radiologists to improve health care delivery.

Failure to notify reportable test results: significance in medical malpractice.

BACKGROUND: Diagnostic physicians generally acknowledge their responsibility to notify referring clinicians whenever examinations demonstrate urgent or unexpected findings. During the past decade, clinicians have ordered dramatically greater numbers of diagnostic examinations. One study demonstrated that between 1996 and 2003, malpractice payments related to diagnosis increased by approximately 40%. Communication failures are a prominent cause of action in medical malpractice litigation. The aims of this study were to (1) define the magnitude of malpractice costs related to communication failures in test result notification and (2) determine if these costs are increasing significantly. EVALUATION: Linear regression analysis of National Practitioner Data Bank claims data from 1991 to 2009 suggested that claims payments increased at the national level by an average of $4.7 million annually (95% confidence interval, $2.98 million to $6.37 million). Controlled Risk Insurance Company/Risk Management Foundation claims data for 2004 to 2008 indicate that communication failures played a role, accounting for 4% of cases by volume and 7% of the total cost. DISCUSSION: Faile communication of clinical data constitutes an increasing proportion of medical malpractice payments. The increase in cases may reflect expectations of more reliable notification of medical data. Another explanation may be that the remarkable growth in diagnostic test volume has led to a corresponding increase in reportable results. If notification reliability remained unchanged, this increased volume would predict more failed notifications. CONCLUSIONS: There is increased risk for malpractice litigation resulting from diagnostic test result notification. The advent of semiautomated critical test result management systems may improve notification reliability, improve workflow and patient safety, and, when necessary, provide legal documentation.

Comparing the interpretations of CT pulmonary angiograms by attending and resident radiologists: can residents identify life-threatening pulmonary emboli in hospitalized patients?

OBJECTIVE: CT pulmonary angiography is now often the first-line investigation for pulmonary emboli. When these studies are performed after hours in teaching hospitals, they are often initially interpreted by trainees. It is of great significance whether the interpretations of trainees and certified radiologists with regard to the presence of pulmonary emboli on CT pulmonary angiograms correspond, because of the morbidity and mortality of both the condition and its treatment. MATERIAL AND METHODS: Twenty-five consecutive CT pulmonary angiograms (CTPAs) of hospitalized patients were viewed at lung and soft tissue windows both on a workstation and on hard copies, at the observers' discretion. Each CTPA was divided into 28 arterial zones based on pulmonary anatomy (including the subsegmental arteries), giving a total of 700 arterial zones, and analyzed retrospectively and independently by two cross-sectional imaging specialists and four residents. Each arterial segment was rated with regard to pulmonary embolus as either high, intermediate, or low probability or not visualized. The kappa (Kappa) test, which tests for interobserver agreement, was used for statistical analysis. RESULTS: At the time of the scan all patients were hospitalized for underlying conditions. Of the 25 patients studied, 9 were referred from the ICU, 7 experienced severe acute shortness of breath and respiratory failure, 5 were post-partum women, 2 had had a recent stroke, 1 patient had antithrombin III deficiency, and 1 had a diagnosis of breast cancer. The incidence of pulmonary emboli was 44%. For the main pulmonary arteries interobserver agreement was good (Kappa=0.61) and for the segmental pulmonary arteries it was fair (Kappa=0.26). For the subsegmental arteries interobserver agreement was poor (Kappa=0.16). The zones where interobserver agreement was greatest (Kappa>0.4) were the left main, left lower lobe, and the right main pulmonary arteries. Interobserver agreement was poorest (Kappa<0.05) in the left interlobar, left lower lobe lateral basal segment, right lower lobe superior segment, and left lower lobe superior segment branches. None of the patients expired due to pulmonary emboli. CONCLUSION: Most life-threatening pulmonary emboli requiring urgent treatment are the more central emboli. This study demonstrates that trainees and certified radiologists can make similar conclusions regarding these central pulmonary emboli in hospitalized patients and that preliminary interpretations by trainees should not therefore adversely affect patient care.