Prof. Adrian Brady. Photo courtesy of Sebastian Kreuzberger/ESR.

In an effort to be helpful, I would like to share four strategies to help reduce reporting errors in radiology. They are not intended to be in any way comprehensive, but they are actions that might help to increase accuracy.

It's important to emphasize that I prefer the term "discrepancy" rather than error for much of what we're considering. The term "error" implies a mistake, and that a clear-cut diagnosis and correct report are possible, but as radiologists we know that there is not always a single definitive outcome from an imaging study.

Imaging is rarely binary -- "normal" or "abnormal." We render an interpretation that is based on our understanding of the patient's condition at the time of the exam. Often an "error" is determined later in the light of additional information and a developing clinical picture. The concept of necessary fallibility must be accepted. However, I will use the term "error" for the purpose of this column, as it is the label most frequently used in literature and discussion.

How prevalent are errors? It seems that 3%-5% is the best minimum error rate achievable even when working in the best of circumstances.¹ Knowing that 1 billion radiologic imaging exams are read annually worldwide, and assuming an average error rate of 4%, that equals approximately 40 million radiologist errors annually.²

Strategy 1: Address cognitive biases in radiology

We all have cognitive biases. They are the result of our brains' attempts to simplify information processing. We cannot rid ourselves of these biases, but we need to be aware of them and take corrective actions to minimize their influence on our reporting.³ The following are only a selection of the many recognized biases to which radiologists are prone, with some suggested corrective measures of varying practical applicability. Admittedly, some of the suggested correction strategies are not feasible in usual radiology practice.

• Anchoring bias -- this is the tendency to rely on our initial impression and fail to adjust it in the light of subsequent information. Correction: Avoid early guesses, and seek to disprove your initial diagnosis rather than confirm it. In some cases, you might want to get a second opinion.
• Framing bias -- this is the result of being influenced by the way a problem is framed. For example, if a referrer states, "The patient may have leprosy," then your interpretation will be influenced by that statement, even though the likelihood of imaging findings being due to leprosy may be remote. Correction: Initially review the study blindly before reading the clinical information.
• Availability bias -- this is the tendency to consider a diagnosis more likely if it readily comes to mind. For example, you are more likely to consider a pathology that you saw in a study the previous day, even if its likelihood is very small. Correction: Try to use objective information to estimate the true base rate of that diagnosis, rather than relying on a quick initial impression.
• Satisfaction of search -- this is the tendency to stop searching for abnormalities once a likely diagnosis or first abnormality is found. Correction: Use a systematic interpretation strategy, perhaps relying on a checklist or algorithmic approach, to help ensure a thorough review. Additionally, do a secondary search after initial abnormality detection, and also consider known combinations (e.g., associated multiple injuries that commonly occur together in the knee).
• Premature closure -- this is the tendency to accept a diagnosis before full verification. Correction: Always give a differential diagnosis. Never make a working diagnosis absolute without pathological confirmation. It's important to make clear that I DON'T advocate this suggested corrective strategy; it would diminish the value created by radiology in patient care).

Strategy 2: Probe for more patient information

I realize that it can be difficult to find time for clinical consultations with our referring colleagues, as well as for direct interaction with our patients. But I strongly believe that these activities are essential to improving our clinical practice. Also, their value is supported by several studies that show a higher percentage of errors occur when reporting is done by offsite reporters who had no opportunity to interact with the referrers or patients, and were presented with only a limited amount of clinical information.⁴ It is part of the job of radiologists to probe for more information when our instincts tell us the picture we have been given is incomplete.

The following are a few helpful actions:

• Discussing the appropriateness and justification of scans
• Tailoring studies to the specific clinical question
• Asking for appropriate missing snippets of history, rather than just proceeding because of time pressures
• Having direct discussions with referrers (including within multidisciplinary team meetings) about the significance of the scan results

Strategy 3: Improve report writing

Sometimes we may interpret imaging studies accurately but be unclear in how we convey our meaning in the written report. From the patient's perspective, the outcome can be the same whether we miss a potential diagnosis or we identify the relevant abnormalities but fail to effectively communicate the key findings and/or their meaning in a poorly written report. If our reports are incoherent, rambling, and verbose -- and if it's impossible for the referrer to clearly understand what is most important in them -- then we have failed to communicate and are as guilty of "error" as if we missed the relevant findings entirely.

In fact, communication failure in general is the fourth most common reason for radiologists in the U.S. being sued, and 60% of these cases were due to a failure to highlight an urgent or unexpected abnormal finding and to emphasize it appropriately in reports.

I recommend you take a look at your own past reports with a fresh set of eyes, or perhaps ask a trusted colleague to read them. Look closely at your report structure, its organization, and your vocabulary choices. Are there mistakes in grammar or punctuation? Have you failed to correct errors in voice-recognition transcription, leading to confusion about your meaning?

I am not a huge fan of structured reporting, but I acknowledge that using them, especially for complex imaging studies, increases thoroughness and accuracy.

My recommendation: Make your reports simple and clear, correct typographical errors, include what matters, do not include the irrelevant.

Strategy 4: Ease mental and visual fatigue

Visual fatigue results from prolonged focusing on a workstation, and it can be alleviated (in part) by accommodative relaxation, shifting your visual focal point from near to far (e.g., looking at a distant object for 15-30 seconds) every 15 minutes.

Mental fatigue is the consequence of continuous and prolonged decision-making. We need to be aware that our cognitive processes respond to this mental strain by taking shortcuts that might result in poor judgment and diagnostic errors.

Below are a few suggestions that might help you ease your mental fatigue:⁵

• Read the most difficult cases at the beginning of your shift when you are fresh.
• Take structured breaks.
• Switch periodically between modalities.
• Reduce unnecessary interruptions and distractions

It is impossible to expect 100% accuracy all the time, even under the best of circumstances. Our working environments in this current era of expected hyperefficient radiology are far from ideal. Radiologist "error" may arise from personal issues, such as the visual and mental fatigue mentioned above, but systemic issues beyond our control (staff shortages, excessive workload, inadequate equipment, poor lighting conditions, lack of availability of previous studies, etc.) are also frequent contributors, and they are unlikely to ever be eliminated completely.

Shifting to a system-centered view of errors

In addition to taking steps to minimize the occurrence of errors, we should also consider our reaction when they do happen. The traditional approach within medicine has been person-centered, with errors viewed as indicative of a personal or professional failure. This culture of "naming, shaming, and blaming" can result in suppression of error reporting as well as missed opportunities to learn from each other's mistakes, and to make process improvements. We need understanding and support from each other and from others in healthcare when mistakes happen.

We should shift our focus to the system, rather than the individual. A system-centered approach facilitates exploration of why an error happened and what can be done to prevent it from happening again. The National Radiology Quality Improvement Programme of the Faculty of Radiologists of the Royal College of Surgeons in Ireland is an example of an effort to embed in practice this more-enlightened and more-beneficial approach to errors.

Also, we as a profession need to educate our patients about error rates. As leaders in radiology like Dr. Giles Maskell have emphasized, there is a yawning gap between what we know to be our error rate and what our patients believe it to be. The discovery in hindsight of an error in interpretation of a radiological image is often perceived by the patient as something shocking and exceptional, calling into question the competence of the radiologist and the overall care they are receiving. It would benefit radiologists if patients, referrers, and others in healthcare better understood the pervasive nature of radiological "error," the inherent uncertainty in much of what we do, and the measures we take to avoid it, while also emphasizing the enormous benefit that radiology -- despite its inherent flaws -- continues to bring to patient care.

In closing, I will share this quote from Sir William Osler, English/Canadian physician, who said, "Errors in judgement must occur in the practice of an art which consists largely in balancing probabilities."

Prof. Adrian Brady is president of the European Society of Radiology and a clinical professor in radiology at University College Cork (UCC), Ireland.

This article was originally published on Carestream's Everything Rad blog: 4 Strategies to Reduce Reporting Errors in Radiology.

References

1. Berlin L. American Journal of Roentgenology AJR (2007);188:1173-1178
2. Bruno MA, Walker EA, Abujudeh HH. Understanding and confronting our mistakes: the epidemiology of error in radiology and strategies for error reduction. Radiographics (2015);35:1668-1676.
3. Lee CS et al, Cognitive and system factors contributing to diagnostic error in radiology, AJR(2013);201:611-617.
4. Accuracy of interpretation of emergency abdominal CT in adult patients who present with non-traumatic abdominal pain; results of a UK national audit. D.C. Howlett, C. Frost, A. Higginson, C. Ball, G. Maskell.
5. Bruno MA, Walker EA, Abujudeh HH. Understanding and confronting our mistakes: the epidemiology of error in radiology and strategies for error reduction. Radiographics (2015); 35:1668-1676.