Page 13 - Diagnostic Radiology - Interpreting the Risks Part Two_Neat

SVMIC Diagnostic Radiology: Interpreting the Risks

CASE STUDY

continued
The abdominal CT was ordered to “rule out a retroperitoneal
bleed”; therefore, the radiologist stated he did not interpret

the scan for bony pathology. Multiple defense experts were
consulted and each concluded the burst fractures were

clearly evident on the abdominal CT. The
radiologist grossly under-interpreted the CT

scan and should have identified the fractures
along with its severity in the report.

Radiologist Leo Henry Garland (1903-1966) was a pioneer in
the study of radiologic error. He discovered that even a skilled

and experienced radiologist failed to note important findings on
30 percent of chest radiographs that were positive for disease

and also had a false-positive rate of approximately 0.2 percent
for negative cases. Since Garland’s time, many excellent studies

of radiologists’ errors have been performed within the United
States and abroad, and they have largely served to confirm and

extend Garland’s findings.

The conclusions reached by these researchers are that

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.

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