Point of Failure
Radiologists will inevitably make mistakes, and they must be prepared to handle them.
About a decade ago, Michael A. Bruno, MD, FACR, professor of radiology and medicine and vice chair for quality and safety at the Penn State Milton S. Hershey Medical Center, was interpreting a patient’s abdominal CT, when he made a mistake. The patient had an unusual partial bowel obstruction, but Bruno misinterpreted the finding.
It wasn’t until a colleague reviewed the images and discovered the obstruction that Bruno realized he had misread the study. “The finding wasn’t classic in any way,” says Bruno, who is also chief of the center’s division of emergency radiology. “I didn’t figure it out, and the diagnosis was delayed as a result.”
Misinterpreted findings are just some of the myriad errors that radiologists face on a daily basis. Errors can creep into a radiologist’s workflow at any point. Some errors are business-related, like failing to develop meaningful relationships with referring physicians, while others directly impact patient care. In fact, the error rate for imaging interpretations is at least 3 to 4 percent and in some cases has been reported as high as 30 percent, depending on the case mix.
“For any given study, the potential for errors is considerable,” says Stephen D. Brown, MD, associate professor of radiology at Boston Children’s Hospital and Harvard Medical School and chair of the RSNA Professionalism Committee. “From dictating the patient history and getting the laterality correct to interpreting the findings accurately and communicating them clearly, mistakes can be made in a lot of areas.”
When radiologists make a mistake, they must acknowledge and address the error. “It’s important for radiologists to understand that all of us are human, and we will all make mistakes no matter how great our intentions are, how well we’re trained, or how careful we are,” says Jonathan S. Lewin, MD, FACR, senior vice president of integrated health care delivery and radiologist-in-chief at Johns Hopkins Medicine. “Failure is part of the business, but it’s important for radiologists to learn from their mistakes, reflect on them, and then move on.”
Before radiologists can address a mistake, they must first realize an error has been made. While interventional radiology mistakes are usually obvious at the time that they occur, diagnostic radiology errors are more nebulous. In fact, diagnostic imagers may never know when they’ve committed an error. “A missed finding may have devastating consequences, but unless the patient shows back up at our hospital or the mistake leads to a malpractice suit, we may never hear about it,” Lewin explains. While a lot of imaging mistakes go undetected, many missteps are uncovered when radiologists review their work, when colleagues detect errors during peer reviews, or when unexpected outcomes occur.
Once radiologists discover their errors, they must take responsibility for their mistakes and follow their practice’s protocols for disclosure. “You have to recognize when risk management needs to be engaged or when your malpractice carrier needs to be called. You also need to know how to inform your chief medical officer and the head of your group,” says Alexander M. Norbash, MD, FACR, professor and chair of radiology at the University of California, San Diego.
In addition to disclosing mistakes to practice leaders, radiologists should discuss their mistakes directly with patients and their families. “From an ethical perspective, a patient deserves to know both when things go well and when they don’t,” Lewin says. “It’s the right thing to do, and I think most patients appreciate the honesty. Whether you’re sitting down with patients and their families to talk about good or bad outcomes, the effort builds radiology’s value in the health care process.”
In the case with the partial bowel obstruction, Bruno met with the patient and the patient’s family in the hospital. He explained that he had misinterpreted the finding and apologized that the patient’s hospital stay, pain, and anxiety had been prolonged as a result. “A lot of people think that reading a film is like reading a book: you open it up, the words are there, and you read them,” Bruno says. “But I explained to the patient and the patient’s family that the process is more like solving a puzzle. I told them that I had not solved the puzzle correctly the first time and that, thankfully, somebody else solved it later. They really appreciated that explanation and my apology, and they understood that some things are not straight forward.”
Once radiologists acknowledge their mistakes, they should try to learn from them as much as possible. They can do this by contemplating the errors and developing a plan to keep from repeating them. “When a patient ends up with a bad or unexpected outcome, the radiologist should try to understand why the outcome occurred and then adjust the approach accordingly to prevent such mistakes in the future,” says Richard B. Gunderman, MD, FACR, chancellor’s professor of radiology, pediatrics, medical education, philosophy, liberal arts, philanthropy and medical humanities, and health studies at Indiana University. “If you’re inquisitive, curious, and spend time thinking critically about how events unfolded, you can learn a lot and become more effective at your job.”
In addition to learning from their mistakes, radiologists must deal with the emotions associated with their errors. Particularly when mistakes lead to adverse patient outcomes, radiologists can become derailed by their own emotions. To overcome this, radiologists must balance empathy with their duties and responsibilities as physicians, Norbash says.
Practices that foster a supportive atmosphere can help radiologists achieve this balance. “If you have a culture where you can discuss issues and errors without fear of retribution, radiologists can process their mistakes more effectively,” says Brown, who helped develop a workshop at Boston Children’s Hospital to teach radiologists effective patient communication. Some practices also have clinical support offices to help radiologists and other medical professionals deal with the psychological effects of mistakes and other issues.
Radiologists can also overcome errors by developing a network of trusted colleagues, family members, and friends with whom they can discuss their mistakes. “If you don’t feel as though you can process the emotions and consequences of a mistake safely within your own practice, then hopefully you’ve developed a network of safe relationships over time where you can process the situation,” Norbash says.
While talking about their errors can be therapeutic, Bruno says that often one of the best things radiologists can do to overcome a mistake is get back to work. “Despite our occasional failure rate, most radiologists do a lot of good every day and that work has a lot of benefits for patients,” Bruno says. “You must remind yourself of that, so you can get back on the horse that knocked you off and continue doing good work for the other patients whose images you’re going to read that day.”
By Jenny Jones, Imaging 3.0 content specialist