Published by De Gruyter

Volume 4 Issue 3 - Special Issue: Improving diagnosis in radiology – progress and proposals / Guest Editors: Michael Bruno, Kevin Johnson, Nick Argy and Mark L. Graber

Issue of Diagnosis

Contents
Journal Overview

Publicly Available September 4, 2017

Editorial

Publicly Available September 4, 2017

Improving diagnosis in radiology – progress and proposals

Michael Bruno, Kevin Johnson, Nick Argy, Mark L. Graber

Page range: 111-112

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Reviews

Publicly Available June 15, 2017

Improving diagnosis in health care: perspectives from the American College of Radiology

Bibb Allen, Mythreyi Chatfield, Judy Burleson, William T. Thorwarth

Page range: 113-124

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Abstract

In September of 2014, the American College of Radiology joined a number of other organizations in sponsoring the 2015 National Academy of Medicine report, Improving Diagnosis In Health Care . Our presentation to the Academy emphasized that although diagnostic errors in imaging are commonly considered to result only from failures in disease detection or misinterpretation of a perceived abnormality, most errors in diagnosis result from failures in information gathering, aggregation, dissemination and ultimately integration of that information into our patients’ clinical problems. Diagnostic errors can occur at any point on the continuum of imaging care from when imaging is first considered until results and recommendations are fully understood by our referring physicians and patients. We used the concept of the Imaging Value Chain and the ACR’s Imaging 3.0 initiative to illustrate how better information gathering and integration at each step in imaging care can mitigate many of the causes of diagnostic errors. Radiologists are in a unique position to be the aggregators, brokers and disseminators of information critical to making an informed diagnosis, and if radiologists were empowered to use our expertise and informatics tools to manage the entire imaging chain, diagnostic errors would be reduced and patient outcomes improved. Heath care teams should take advantage of radiologists’ ability to fully manage information related to medical imaging, and simultaneously, radiologists must be ready to meet these new challenges as health care evolves. The radiology community stands ready work with all stakeholders to design and implement solutions that minimize diagnostic errors.

Publicly Available September 4, 2017

The role of radiology in diagnostic error: a medical malpractice claims review

Dana Siegal, Lindsay M. Stratchko, Courtney DeRoo

Page range: 125-131

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Abstract

Just as radiologic studies allow us to see past the surface to the vulnerable and broken parts of the human body, medical malpractice claims help us see past the surface of medical errors to the deeper vulnerabilities and potentially broken aspects of our healthcare delivery system. And just as the insights we gain through radiologic studies provide focus for a treatment plan for healing, so too can the analysis of malpractice claims provide insights to improve the delivery of safe patient care. We review 1325 coded claims where Radiology was the primary service provider to better understand the problems leading to patient harm, and the opportunities most likely to improve diagnostic care in the future.

Publicly Available August 14, 2017

Medical errors, malpractice, and defensive medicine: an ill-fated triad

Leonard Berlin

Page range: 133-139

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Abstract

For the first 180 years following the founding of the US, physicians occasionally were sued for medical malpractice. Allegations of negligence were errors of commission – i.e. the physician made a mistake by doing something wrong, usually mistreatment of a fracture or dislocation, a complication or death following a surgical procedure, prescribing the wrong medication, and after the discovery of the X-ray by Roentgen in 1895, causing radiation burns. In the mid twentieth century malpractice allegations slowly changed from errors of commission to errors of omission – i.e. the physician failed to do something right: almost always, failed to make a diagnosis. The number of malpractice lawsuits increased at a geometric rate beginning in the 1960s, and in the 1970s physicians began practicing defensive medicine, which lead physicians to order unnecessary radiology exams and tests. In the past 20 years the number of malpractice lawsuits has been decreasing, but the practice of defensive medicine has continued. Unnecessary exams and tests increase the likelihood of overdiagnosis and overtreatment, i.e. a new kind of error of commission.

Publicly Available July 4, 2017

Perceptual errors in pediatric radiology

George A. Taylor

Page range: 141-147

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Abstract

Perceptual errors are common contributors to missed diagnoses in the clinical practice of radiology. While the physical attributes of an image such as image resolution, signal-to-noise characteristics, and anatomic complexity are major causes of poor conspicuity of pathologic lesions, there are major interrelated cognitive contributors to visual errors. The first is satisfaction of search (SOS), where the detection of an abnormality results in premature termination of further search. Another form of incomplete search pattern is visual isolation, where a radiologist’s search pattern is truncated to the main areas of an image, while little or no attention is given to peripheral areas. A second cognitive error is inattentional blindness, defined as the failure to notice a fully visible, but unexpected object because attention was otherwise engaged. Strategies for error mitigation have centered around the use of check lists, self prompting routines, and structured reporting within an institutional culture of safety and vigilance.

Publicly Available July 28, 2017

256 Shades of gray: uncertainty and diagnostic error in radiology

Michael A. Bruno

Page range: 149-157

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Abstract

Radiologists practice in an environment of extraordinarily high uncertainty, which results partly from the high variability of the physical and technical aspects of imaging, partly from the inherent limitations in the diagnostic power of the various imaging modalities, and partly from the complex visual-perceptual and cognitive processes involved in image interpretation. This paper reviews the high level of uncertainty inherent to the process of radiological imaging and image interpretation vis-à-vis the issue of radiological interpretive error, in order to highlight the considerable degree of overlap that exists between these. The scope of radiological error, its many potential causes and various error-reduction strategies in radiology are also reviewed.

Publicly Available August 18, 2017

Using Bayes’ rule in diagnostic testing: a graphical explanation

Kevin M. Johnson

Page range: 159-167

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Abstract

In the context of diagnostic testing, concepts such as sensitivity, specificity, predictive values, likelihood ratios and more are all interconnected, but precisely how can be confusing to the nonstatistician. This paper presents a graphical explanation. Bayes’ rule, or theorem, ties several of these concepts together and should have a role in careful diagnostic thinking. It too can be understood in terms of the “two-by-two diagram” presented here.

Publicly Available August 25, 2017

X-ray art images: objects from nature

George Taylor

Page range: 169-172

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Mini Review

Publicly Available June 15, 2017

Assigning responsibility to close the loop on radiology test results

Janice L. Kwan, Hardeep Singh

Page range: 173-177

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Abstract

Failure to follow-up on test results represents a serious breakdown point in the diagnostic process which can lead to missed or delayed diagnoses and patient harm. Amidst discussions to ensure fail-safe test result follow-up, an important, yet under-discussed question emerges: how do we determine who is ultimately responsible for initiating follow-up action on the tests that are ordered? This seemingly simple question belies its true complexity. Although many of these complexities are also applicable to other diagnostic specialities, the field of medical imaging provides an ideal context to discuss the challenges of attributing responsibility of test result follow-up. In this review, we summarize several key concepts and challenges in the context of critical results, wet reads, and incidental findings to stimulate further discussion on responsibility issues in radiology. These discussions could help establish reliable closed-loop communication to ensure that every test result is sent, received, acknowledged and acted upon without failure.

Opinion Papers

Publicly Available June 15, 2017

Information overload: when less is more in medical imaging

James R. Duncan

Page range: 179-183

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Abstract

In medicine, data collection and analysis provide the information needed to reduce diagnostic uncertainty. An examination of how medical imaging data is collected and then transformed into diagnostic information provides testable ideas for better managing this dynamic process. In other fields, process data is systematically assessed for differences between observed and predicted values. For studies that expose patients to the potentially harmful effects of ionizing radiation, monitoring imaging studies/illness, images/imaging study and radiation exposure/image would be steps towards developing radiation dose budgets for the diagnosis and treatment of common conditions. Random variation within the expected range would signal a high quality process. Conversely, single outlying cases or nonrandom variation within the expected range would trigger an investigation for a possible underlying cause. Such investigations would provide insights into how to continually improve this important aspect of healthcare.

Publicly Available August 28, 2017

Radiology education: a radiology curriculum for all medical students?

Laura Zwaan, Ellen M. Kok, Anouk van der Gijp

Page range: 185-189

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Abstract

Diagnostic errors in radiology are frequent and can cause severe patient harm. Despite large performance differences between radiologists and non-radiology physicians, the latter often interpret medical images because electronic health records make images available throughout the hospital. Some people argue that non-radiologists should not diagnose medical images at all, and that medical school should focus on teaching ordering skills instead of image interpretation skills. We agree that teaching ordering skills is crucial as most physicians will need to order medical images in their professional life. However, we argue that the availability of medical images is so ubiquitous that it is important that non-radiologists are also trained in the basics of medical image interpretation and, additionally in recognizing when radiological consultancy should be sought. In acute situations, basic image interpretations skills can be life-saving. We plead for a radiology curriculum for all medical students. This should include the interpretation of common abnormalities on chest and skeletal radiographs and a basic distinction of normal from abnormal images. Furthermore, substantial attention should be given to the correct ordering of radiological images. Finally, it is critical that students are trained in deciding when to consult a radiologist.

Letter to the Editor

Publicly Available August 18, 2017

Demonstration Collaborative project to reduce emergency department radiologic diagnostic errors

Rebecca Jones

Page range: 191-191

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About this journal

Objective
Diagnosis is a subscription journal, which focuses on how diagnosis can be advanced, how it is taught, and how and why it can fail, leading to diagnostic errors. The journal welcomes both fundamental and applied works, improvement initiatives, opinions, and debates to encourage new thinking on improving this critical aspect of healthcare quality. Diagnosis is the official journal of the Society to Improve Diagnosis in Medicine.

Please submit your manuscript here

Topics

Factors that promote diagnostic quality and safety
Clinical reasoning
Diagnostic errors in medicine
The factors that contribute to diagnostic error: human factors, cognitive issues, and system-related breakdowns
Improving the value of diagnosis – eliminating waste and unnecessary testing
How culture and removing blame promote awareness of diagnostic errors
Training and education related to clinical reasoning and diagnostic skills
Advances in laboratory testing and imaging that improve diagnostic capability
Local, national and international initiatives to reduce diagnostic error

Article formats

Research Reports – Reports of original research
Short Communications – Reports of early research results and pilot studies
Reviews – Systematic, narrative, and focused reviews. Review articles are normally published by invitation, but suggestions to the Editors are welcome
Opinion Papers and Editorials
Letters to the Editor
Point/Counterpoint Papers
Guidelines and Recommendations
Innovations in diagnostic testing – Advances in laboratory testing or diagnostic imaging are appropriate subjects, or evaluations of recent innovations
Case Reports – Learning from Tragedy – Case reports of diagnostic error or dilemma discussed from a multi-stakeholder perspective; should include the facts of the case, a discussion focused on a root cause analysis, take-away points or action items resulting from the analysis, and whenever possible input from both the affected patients and their providers
Case Reports – Lessons in Clinical Reasoning: Pitfalls, Myths, and Pearls – Case reports in which a clinician discusses their diagnostic approach after clinical information is presented, focusing on a case in which a diagnostic error (or near miss = great catch) occurred
Patient-Focused Articles – Papers in this category should be written in lay language on a topic of interest to the patient stakeholder community
Diagnosis in the News – Brief reports of news-worthy advances in diagnosis, or problems involving diagnostic error

Volume 4 Issue 3 - Special Issue: Improving diagnosis in radiology – progress and proposals / Guest Editors: Michael Bruno, Kevin Johnson, Nick Argy and Mark L. Graber

Issue of Diagnosis

Frontmatter

Improving diagnosis in radiology – progress and proposals

Improving diagnosis in health care: perspectives from the American College of Radiology

Abstract

The role of radiology in diagnostic error: a medical malpractice claims review

Abstract

Medical errors, malpractice, and defensive medicine: an ill-fated triad

Abstract

Perceptual errors in pediatric radiology

Abstract

256 Shades of gray: uncertainty and diagnostic error in radiology

Abstract

Using Bayes’ rule in diagnostic testing: a graphical explanation

Abstract

X-ray art images: objects from nature

Assigning responsibility to close the loop on radiology test results

Abstract

Information overload: when less is more in medical imaging

Abstract

Radiology education: a radiology curriculum for all medical students?

Abstract

Demonstration Collaborative project to reduce emergency department radiologic diagnostic errors