Close Calls

Radiologists remember the cases they almost missed and the things they learned in the process.close calls

It's an unfortunate truth that one of the best ways to learn is by making mistakes. Few things burn an idea into our minds the way a negative event can, especially one that we could have prevented.

But what about near misses, those not-quite mistakes that make us stop in our tracks and feel grateful for a second chance?

The authors of a recent study exploring near misses in radiology point out that close calls are often understudied and, perhaps, underutilized as learning experiences. "Such events, though rich with opportunities for free learning about system vulnerabilities, often receive little attention because they are not associated with bad outcomes," the researchers found. "Actual adverse events and active patient complaints tend to consume the bulk of quality, safety, and risk management resources in health care, limiting the time available for analysis of things that only nearly went wrong."1 While the radiology community may not devote significant resources to studying things that did not actually go wrong, individual radiologists do not treat these experiences lightly.

Check and Double Check

C. Matthew Hawkins, MD, a pediatric radiology fellow at Cincinnati Children's Hospital Medical Center, recalls an instance in which his colleagues were performing a fluoroscopy examination on a child who had loosely been categorized as failing to thrive. They have the child contrast to drink and then watched the liquid move down the esophagus, through the stomach, and into the proximal jejunum. The radiologists were focused on the upper gastrointestinal tract, the study's target area, but they were also using the hospital's structured report to record their findings. One of the items on the report prompted them to take another look at the study: "the bones are normal."

"That made us pause and take a second look at the bones," says Hawkins. "and we realized the ribs didn't look right." Based on the appearance of the ribs, additional radiographic studies were ordered, which turned up findings consistent with non-accidental trauma. "that's a dramatic example but a very real story," Hawkins says. "It is not a finding that we commonly look for on an upper GI barium exam." As a result of this experience, Hawkins approaches cases with a different perspective. "This experience taught me to maintain suspicion and openmindedness about all potential diagnoses when interpreting exams," he says.

Alexander J. Towbin, MD, Neil D. Johnson Chair of Radiology Informatics and assistant professor of radiology and pediatrics at Cincinnati Children's Hospital Medical Center, has had similar experiences with the hospital's structured reporting system. "Several time I've been reading through a chest X-ray and been about to call it completely normal, but there's that item on the report asking about the bones," he says. The structured reporting system became something of a checklist, prompting him to look at the bones on an abdominal X-ray, which he may not have otherwise done.

Beyond the Report

When we think of a typical miss, it's usually a clinical finding that comes to mind: an overlooked pulmonary nodule or a passed-over cluster microcalcification. But Richard B. Gunderman, MD, PhD, FACR, professor of radiology, pediatrics, medical education, philosophy, liberal arts, and philanthropy at Indiana University, takes it a step further. "I think our misses extend beyond simply failing to detect lesions or offering an inaccurate differential diagnosis," he says. "Sometimes we fail to appreciate the human meaning of the lesions we detect and appropriately diagnose."

Most radiologists can point to a handful of cases in their careers that impacted them more than the rest. For Gunderman, one such case involved a different kind of miss. While working his way through his cases one day, Gunderman read the case of a Nobel laureate whose research had paved the way for modern chemotherapy treatments.

"From a radiological point of view, I did a very fine job of describing the findings on his noncontrast head CT," says Gunderman. "I told the emergency department doctors and the neurologists exactly what they needed to know. But there was a lot more going on with the patient. That patient meant a lot more than what the CT scan disclosed.

While Gunderman had no regrets about the interpretation he delivered, he failed to appreciate the person behind the images. "I was in such a hurry to just move through exams, do what needed to be done and nothing more, that I really never paused to think about who that person was and what a poignant story lay behind those images," recalls Gunderman. "I didn't start to really think about it until the next day. And I guess I've been thinking about it for the intervening 15 or so years."

After this humbling experience, Gunderman changed very little about his actual reading technique. However, his approach to his patients would never be the same. "I'm far from perfect, but I do think that I am better than I would have been, a little bit more sensitive and respectful of the life stories that lay behind the images we work with every day," he says. "I can't prove that it's enabled me to provide higher quality of care by any conventional measures, but I just think as human beings that we have a responsibility to remember that the cancer or the stroke or the severe traumatic injury we're seeing on those images isn't just an injury or a disease in a tissue or an organ. We're talking about somebody's life here."

Reality Check

While no radiologist expects perfection, the vast majority strive towards it. When they fall short of their own expectations, wise radiologists frame a close call as a glimpse into a negative scenario that could have become reality. "As radiologists, we're always learning," says Towbin. "We're always trying to get better. And that is why we need to take advantage of these 'free lessons.' In our department, we encourage our radiologists to submit these good catch cases for inclusion in our peer review conference so that we can learn from one another's experiences."

Hawkins also points to lessons learned from close calls. "That near miss taught me that sometimes it's when you take a second look that you find the most important thing," he says. "And sometimes it's not at all what you thought you were looking for."

1. Thornton RH, Miransky J, Killen AR, Solomon SB, Brody LA. “Analysis and Prioritization of Near-Miss Adverse Events in a Radiology Department.” American Journal of Roentgenology 2011;196(5):1120–24.

By Lyndsee Cordes

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