The patient returned to the ED the following day and, on further review of the patient's initial radiographs (keeping in mind the context of the physical examination), a repeat shoulder radiograph was obtained. This radiograph clearly showed a clavicle fracture (Figure 4).
This case reinforces the following points:
When evaluating radiographs, careful attention must be paid to the clinical examination findings.
Before any images are obtained, all hospital and nonhospital attachments must be removed from the body part that is being examined.
The reported incidence of errors in the interpretation of radiologic studies in the ED widely varies. One study examining the competency of five senior surgical residents compared with radiologists in a Level II trauma center showed a 99.2% rate of agreement; the residents identified 127 injuries, whereas 128 were identified by the radiologists (the radiologists missed one finding and the residents missed two).
Other studies have shown error rates ranging from 2% to 16% for plain radiographs interpreted by nonradiologists.[2,3] A study by Russell and colleagues showed error rates as high as 29%. In that study, two of the errors led to serious management issues. Consequently, much reflection is required to determine where errors in radiologic interpretation stem from.
Errors in radiology may be broadly classified into the two following categories: perceptual/cognitive errors (false-positive, false-negative, and misinterpretation) and other types of error (eg, complications from procedures and communication lapses). Errors in the ED environment are primarily of the perceptual-cognitive type.
A false-positive error is an error of overreading, in which a finding is appreciated by the clinician but is in fact not present. However, false-negative results are more common, in which findings that are true are missed. False-negatives may result from a lack of knowledge or a failure to isolate important material, or they may occur because of limitations in the examination. Misclassification, the final type of perceptual/cognitive error, occurs when an abnormality is recognized but is interpreted incorrectly.
In this case, the error would be classified as a false-negative interpretation of the film. The proximal cause of the error, however, was not misinterpretation. Rather, it was the failure to ensure an adequate examination by not removing the extraneous radio-opaque material (the monitoring electrodes) and repeating radiography.
Other common examples of this kind of error in the trauma setting include failure to obtain proper views when visualizing a scaphoid fracture on plain radiography, failure to insist on complete inspiration during chest radiography, and failure to obtain adequate views to visualize the C7/T1 interface on lateral cervical-spine films. The American College of Radiology and the Physician Insurers Association of America report that faulty technique is responsible for 10%-30% of radiologic medical-malpractice claims.
Such mistakes as these are fairly simple to avoid by implementing a systems-thinking approach, which in this particular case would have been implementation of (and adherence to) a simple rule. In a systems approach, errors are seen as being shaped and provoked by upstream systemic factors, such as organizational culture, risk management, or lack of resources. A longitudinal study of reducing errors in radiographic interpretation by emergency physicians demonstrated that implementing a systemic approach reduced errors from 3% to 0.3% over a 3-year period. In that particular study, a policy was implemented wherein radiographs were brought directly to emergency physicians for interpretation and subsequently reexamined by radiologists within 12 hours. In the event of a clinically significant misinterpretation, the staff contacted the patients and asked them to return.
Although the error in this case was missed by both the emergency physician and the radiologist, a systems-based approach to radiograph interpretation, with strict insistence on proper visualization and systematic identification of landmarks during radiographic interpretation, might well have prevented the error. Other errors that fall under the perceptual/cognitive category are multifactorial and, therefore, are more difficult to address.
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