Guidelines for minimising false findings in radiology

Medical imaging makes important contributions to diagnostics, but it is also a potential source of errors. How can the most common errors be avoided?

Misdiagnosis in radiology, a taboo subject

Radiological image interpretation is a human endeavour based on complex psychophysiological and cognitive processes. At present, it can neither be mechanised nor automated. For some, it is even an art that requires a great deal of knowledge and imagination. However, "misdiagnosis" is dangerous and a sensitive issue for radiologists.

The exponentially increasing number of examinations and the dependence of modern medicine on imaging procedures is leading to more stress among radiologists and thus to avoidable errors. However, many clinics lack an active error culture: instead of creating structures for teaching and discussing findings, the skills of young radiologists are questioned and even criticised on a personal level.

Radiological errors: what does science say?

Despite technological advances and improved working conditions, the overall prevalence of errors in radiology has remained unchanged since it was first estimated in the 1960s. It is therefore important to deal with misinterpretation scientifically and systematically. Radiologist Leo Henry Garland (1903-1966) was a pioneer in the field of radiological error research.1 Based on his research, two types of error were recognised:

Perceptual errors are far more common and account for 60-80% of errors made by radiologists.2

An increased incidence of perception errors can be attributed to specific internal and external risk factors. External factors include poor recognisability of the target lesion on the image, distractions such as phone calls, emails and smartphones. Internal factors include physician fatigue (e.g. on night duty), a fast pace for interpretation, and an important phenomenon known as satisfaction of search. Here, the discovery of an abnormality on one image leads to a second abnormality being overlooked because the radiologist is "satisfied" with the results of his or her search.

Cognitive or interpretive errors occur when an abnormality on an image is recognised but its meaning is misunderstood, leading to an incorrect final diagnosis. This type of error may be due to a lack of knowledge, a cognitive bias on the part of the radiologist interpreting the examination, or misleading clinical information that distorts the apparent likelihood of disease prior to the examination.

It may also simply be due to a radiologist inadvertently passing on an error made by a colleague in a previous report (sometimes referred to as alliterative error or satisfaction of report).

Kim and Mansfield took the trouble to analyse 1,269 erroneous findings and classify them into twelve different categories according to cause.3

How can misdiagnosis in radiology be reduced?

In my opinion, the most important basis for the correct handling of misdiagnoses in radiology is the open handling and de-tabooing of errors. Statements such as "Every radiologist has missed something" and "It happens to the best" ensure a relaxed atmosphere in the department and better communication between colleagues. The next step is to analyse the error objectively and constructively: was it an error of perception due to external factors? Was it an interpretation error in an organ system that the diagnostician is not familiar enough with? This analysis, accompanied by feedback and discussion of the findings, can effectively help to avoid errors of the same kind.

Checklists and structured reporting have proven to be "best practices" in medicine for quality assurance and reducing errors.4 With systematic reporting and a dedicated Scheme F, satisfaction of search can be avoided and anomalies recognised - even if they have never been seen before.

In summary, radiological errors can lead to a significant deterioration in patient outcome. In order to reduce errors in radiology, resources should be allocated into young radiologists' training. An open approach to errors and constructive discussions of findings contribute to self-confidence and increased performance in radiology, and thus to a reduction in misdiagnoses.

  1. Graber M, Gordon R, Franklin N. Reducing diagnostic errors in medicine: what's the goal? Acad Med. 2002 Oct;77(10):981-92. doi: 10.1097/00001888-200210000-00009. PMID: 12377672.
  2. Samei E, Krupinski E. Medical image perception. In: Samei E, Krupinski E, eds. The handbook of medical image perception and techniques. Cambridge, England: Cambridge University Press, 2010
  3. Kim YW, Mansfield LT. Fool me twice: delayed diagnoses in radiology with emphasis on perpetuated errors. AJR Am J Roentgenol 2014;202(3):465–470.
  4. Rosen MA, Pronovost PJ. Advancing the use of checklists for evaluating performance in health care. Acad Med 2014;89(7):963–965.