Page 47 - 2022 Risk Basics - Radiology

SVMIC Risk Basics: Radiology

seizure while waiting to have a second CT performed. The second CT

revealed a fractured skull, epidural hematoma, and brain herniation.
After suffering a second seizure, the patient was comatose for two

months. He has devastating neurologic injuries and flaccid left side. He
lost some vision in both eyes and has no control of bowel and bladder

functions. He cannot perform the tasks of daily living.

The findings on the first CT were subtle. Experts disagreed as to
whether missing these findings was a deviation from the standard of

care. Our very experienced defense expert on a blind reading, given
no information except a history of head trauma and neck pain, did not

see the fracture or the hematoma. After being shown the second CT,
however, he had no difficulty finding the fracture and hematoma. In

hindsight, the injuries were “very obvious”. As our expert said, “This
is a tough one, because we are supposed to see this, even though

obviously he (and I) did not without seeing the second CT,” concluding,
“maybe, I went too fast.”

The jury apparently did not lack the clarity of the two radiologists. The
plaintiff was awarded a multi-million dollar verdict.

Distractions are also a major contributing factor to diagnostic errors.
Radiologists spend a significant amount of time toggling between

medical tasks such as examination interpretation, consulting with

referring physicians, and nonmedical functions such as answering
telephone calls and returning pages. Other interruptions unrelated to
20
the case may include responding to texts or emails and “surfing the net”.

Multi-tasking also has the potential to introduce errors. Correlating the

number of telephone calls received by an overnight on-call resident with
resident-attending discordant interpretations, it was found in one study

20 Balint BJ, Steenburg SD, Lin H, Shen C, Steele JL, Gunderman RB. “Do telephone call interruptions have an
impact on radiology resident diagnostic accuracy?” Acad Radiol 2014; 21:1623–1628

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