Learning objectives
Any man can make mistakes,
but only an idiot persists in his error.Cicero.
To err is human,
but more so is to blame it on others.
Baltasar Gracián.
Learning Objectives:
This poster shows a spectrum of the most common errors in our experience of double-reading spine studies,
trying whenever possible to determine the diagnostic error involve in each example.It aims to (1) clarify the concept of diagnostic error; (2) show a spectrum of the most common diagnostic mistakes,
and (3) provide strategies to minimize them.
Background
Most of the misdiagnoses occur by a combination of factors in the radiological process.
Part of our work as radiologists is to detect and analyse their causes.
Our poster is focused on common diagnostic errors.
A diagnostic error consists in the omission or incorrect interpretation of a radiological finding [1].
The most common radiological error in spine is the omission of fractures.
It is considered the main cause of legal action against radiologists,
after failing to detect breast and lung cancer [2].
Since the publication...
Findings and procedure details
Spectrum of diagnostic errors in the vertebral spine
Radiology depends essentially on the identification and interpretation of visual findings,
thus perception biases and cognitive have a more important role than in other areas [11].
While the training can improve the diagnostic radiologist threshold,
some of these processes are not always subject to conscious control by the human mind [7].
Errors of perception:
They consist of the omission of a finding that is present in the image [2,
8,
18].
They are the most common (80%)...
Conclusion
Approach to errors and culture of the error
Active errors or diagnostic errors committed by the radiologist are subject to mental traps or psychological biases,
and are difficult to control.
It is part of our job to use strategies to minimize them,
implement training sessions on errors,
double reading,
lifelong learning,
and seek consultation with other colleagues or feedback (feedback) from the requester on the final diagnosis.
Our culture and education has tended to stigmatize the error and the people who commit it.
This favours...
References
Whang JS,
Baker SR,
Patel R,
Luk L,
Castro A 3rd.
The causes of medical malpractice suits against radiologists in the United States.
Radiology.
2013; 266:548-54.
PintoA,Brunese L.
Spectrumofdiagnostic errorsinradiology.
World J Radiol.2010; 2:377-83.
Kohn LT,
Corrigan JM,
Donaldson MS.
To err is human: building a safer health system.
Washington DC: National Acadamy Press,
2000.
Baker SR,
Lelkes V,
Patel RH,
Castro A 3rd,
Sarmast U,
Whang J.
Spinal-related malpractice suits against radiologists in the USA-rates,
anatomic location,
percent of adverse judgments,
and average payments....