In this poster we present the errors of radiology trainee’s preliminary reports during out-of-hours cover, in a tertiary hospital with specific interest in emergency radiology.
To reframe mistakes into a learning opportunity for others and provide practical suggestions to reduce future errors.
BACKGROUND & METHODS
Human error is a normal phenomenon. Learning from errors is part of the training process to become a better radiologist.
We retrospectively identified errors in the preliminary reports issued by radiology trainees during out-of-hours reporting in a tertiary referral hospital. A retrospective search using key words “addendum” for out-of-hours report issued by registrars over a 6-month period, was performed. Errors from the preliminary reports were identified by the consultant radiologists. Selections of images highlighting missed pathologies or false interpretations are highlighted through...
Imaging findings OR Procedure details
CASE 1: 60-year-old female with shortness of breath and intermittent chest pain. Axial CTPA demonstrated faint peripheral areas of non-opacification of the right middle lobe segmental pulmonary artery thought to be secondary to pulmonary embolism on the preliminary report. This is favoured to be secondary to cardiac motion artifacts with partial volume of the adjacent pulmonary parenchyma mimicking a filling defect. The differential diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH) was raised and would be best demonstrated on modalities such as VQ scan or MR...
We highlight radiology trainees' report errors in our institute to outline blind spots and commonly missed pathology in the interpretation of emergency CT imaging. Learning from mistakes is an important tool to be become a better radiologist.
Young W. Kim, Liem T. Mansfield (2014) Fool me twice: delayed diagnoses in radiology with emphasis on perpetuated errors. AJR 202: 465 – 470.