Radiology malpractice is more common than many people realize. Over 80 million radiology examinations are performed in the United States every year. These radiology examinations include Magnetic Resonance Imaging (MRI), Computed Tomography (CT or CAT scan), Positron Emission Tomography (PET scan), and x-ray studies also known as plain radiographs. Given the immense volume of imaging studies and high expectations on radiologists to interpret those studies with speed and accuracy, it’s no surprise radiology is the eighth most common medical specialty to be implicated in a medical malpractice claim.
Research shows radiologists misinterpret or miss findings entirely on 3%-5% of radiology studies each day. This means that radiologists around the world are reaching the wrong or incomplete conclusion 40 million times each year! (Brady 2016).
Radiologists are trained to look at every part of each image when they review a radiology study. Likewise, while a physician must identify the “indication” or reason why they are ordering the exam and communicate the indication to the radiologist, the radiologist must look for and report all abnormal findings, whether or those findings are related to the reason the treating physician ordered the exam. For example, if a patient’s physician orders a chest x-ray to look for signs of a pneumothorax (collapsed lung), and the radiologist, separate and apart from the pneumothorax, discovers an abnormal mass, the radiologist must report the mass to the physician who ordered the study even though the mass has no relationship radiologically to the collapsed lung.
Unexpected findings discovered on radiology exams like the mass in the above example are known as “incidental” findings or “incidentalomas.” Such findings are deemed incidental because they are unrelated to the reason for the exam, but may nevertheless have significance to the health of the patient. Radiologists are expected to identify incidental findings apparent on radiology images.
One of the most frequent and devastating mistakes in radiology is the failure to identify a potentially cancerous mass. Some of the most common types of cancers which are missed on radiology studies include colorectal carcinoma on barium enema studies, tumors of the bone on plain x-rays, and breast nodules or tumors on screening mammography. However, probably the most common form of delayed diagnosis of cancer comes in the form of missed lesions of the lung on plain x-ray. (Pinto 2010). The rate by which radiologists miss nodules or other lesions on x-ray images that are later diagnosed as lung cancer has been reported to range from 12% to 90%. (Tack 2019).
The Root Causes of Mistakes by Radiologists
Broadly speaking, radiologists are susceptible to misinterpreting radiology images and missing important findings entirely. A common root cause of medical mistakes in radiology can be traced to errors in perception by the radiologist. These errors in perception are thought to be related to cognitive factors that influence how radiologists process the images before them and make decisions about their findings. (Lee 2013) For example, experienced radiologists may instinctively rely on certain methods they learned during their training and develop over time to interpret radiology exams more quickly and efficiently. Known as heuristics, the methods enable a less analytical and more intuitive form of thinking psychologists describe as “fast thinking”.
While heuristics can help radiologists meet the daily demands of their job, they make radiologists more prone to certain pitfalls in thinking, known as cognitive bias. (Busby 2018) Various forms of cognitive bias create a trap for the perception of the radiologist and increase the risk of error. Examples of cognitive bias in radiology include:
- Confirmation Bias – This defect in thinking occurs when a radiologist reaches an initial diagnosis and then limits the remainder of their review to looking for findings that confirm the initial diagnosis rather than looking for aspects of a study that would support alternative diagnoses.
- Anchoring bias – When a radiologist refuses to change his or her initial diagnosis, in spite of information that suggests a contrary diagnosis.
- Satisfaction of Search – The bias occurs when a radiologist identifies an initial abnormality, and as a result of this finding rests their vigilance and focus to the point of overlooking other important abnormalities
Systemic factors can also impact the accuracy of a radiologist’s work. Hospitals and practice groups often require radiologists meet a demanding measure of productivity. Long shifts and the high volume of complex work can lead to visual and mental fatigue. (Lee 2013) Proving the point, recent findings from a study examining 4294 discrepancies between preliminary and final interpretations of radiology studies showed diagnostic errors were more likely to occur in association with heavier caseloads, longer shifts, and at times closer to the end of shifts. (Hanna 2018)
Errors in communication lead to missed opportunities
Medical malpractice can also be traced to errors in communication of critical radiology findings. Breakdowns in communication can allow cancerous tumors to grow untreated while patients and their physicians remain in the dark. In these cases, radiologists may skillfully identify incidental findings on radiology studies. Yet, breakdowns in communication between radiologists and the physicians treating patients can lead to catastrophic injury or death.
For example, a radiologist may identify an unusual pelvic mass on an abdominal CT scan, but only report the mass in the most detailed section of the radiology report known as “Findings”. Meanwhile, the physician who ordered the study, whether a busy emergency room doctor or general practice physician seeing four patients every hour, may not take the time to read the radiologist’s detailed findings. Instead, the treating physician will only read the summary of findings in the “Impressions” section of the radiologist’s report. As a result, the pelvic mass will remain undiagnosed and untreated within the patient until it has increased in size by double or more.
In many cases, the increase in the size of an untreated mass will put the patient at risk of injury from compressing or displacing nearby structures within the body. When the mass is untreated cancer, the tumor will spread cancer to other parts of the body as it grows undetected and reduce the patient’s chance of beating their disease.
Another example of errors in communication involve radiology studies ordered for patients receiving care in emergency departments. Emergency department physicians can make treatment decisions based on preliminary interpretations of radiology exams. Such preliminary reports are often written by radiologists still training as residents. Hours later, sometimes after the patient is discharged from the hospital, a supervising radiologist will review the same images and provide their own findings in a final report. The final report may contain important findings not described in the resident radiologist’s preliminary report. However, the emergency physician who cared for the patient may never read the final report or learn about the new finding. Ultimately, there is a chance no physician will learn of the new finding or take responsibility for notifying the patient.
But medical negligence can occur even when suspicious findings are properly communicated by radiologists to treating physicians. Radiologists commonly make recommendations for further testing using a type of radiology exam that shows details of parts of the anatomy the subject exam doesn’t provide, such as muscles, the flow of blood through vessels, or the path spinal fluid takes through a diseased spinal canal. For example, a radiologist might recommend an MRI or CT scan to provide more detail about findings seen on a bone scan. It is standard practice for radiologists to list potential diagnoses in their report (called “differential diagnosis”), including conditions like “infection, inflammation, or metastasis.” Radiologists make recommendations or list potential diagnoses not only to alert the treating physician, but to help treating physicians reach a diagnosis that can mean the difference between life and death. Still, physicians who order radiology exams are prone to the same types of cognitive bias and influenced by the same extrinsic pressures which cause radiologists to misinterpret or miss critical findings. As a result, physicians fail to take action in spite of radiologists’ best efforts to call potentially harmful findings to their attention.
Another aspect of radiology, which often leads to communication errors, is the extent to which the radiologist must make sure the ordering doctor is made aware of an abnormal finding. Effective communication between the radiologist and ordering physician is a critical component of effective and safe diagnostic imaging. Oftentimes, effective and timely communication by a radiologist requires “nonroutine” communication. Routine reporting of imaging findings is communicated through normal channels established by hospital or diagnostic imaging facility policy and procedure. “Normal” channels of communication consist of delivery of the radiologist’s report, including radiologic findings and impressions, to the ordering physician with carbon copies sent to any other relevant members of the patient’s medical care team. In emergent or other nonroutine clinical situations (e.g. an abnormal incidental finding), the interpreting radiologist is required to expedite the delivery of the radiology report in a manner that reasonably ensures timely receipt of the findings by the patient’s treating doctor(s). Depending on the circumstances, the radiologist may also be required to notify the patient directly.
In a Practice Parameter for radiologists, the American College of Radiology (ACR), has outlined three situations which may warrant nonroutine communication: 1. Findings that suggest a need for immediate or urgent intervention (e.g. pneumothorax or misplaced line or tube); 2. Findings that are different from preceding radiology interpretations and which may cause harm to the patient if not timely addressed; and 3. Findings that the interpreting physician reasonably believes may be seriously adverse to the patient’s health and may not require immediate attention but, if not acted on, may worsen over time and possibly result in an adverse patient outcome (e.g. a potentially malignant lung mass found incidentally).
In its Practice Parameter, the ACR describes the appropriate methods for “nonroutine” communications of radiology findings. In short, the ACR notes that nonroutine communications be handled in a manner most likely to reach the attention of the treating or ordering physician/health care provider in time to provide the most benefit to the patient. Communication by telephone or in person to the treating or ordering physician or his/her representative is appropriate and assures receipt of the findings. While other forms of communication like fax, cell phone text messaging or voice messaging may communicate the necessary information they are discouraged because of the risk they pose of being ineffective.
The medical malpractice attorneys of Lupetin & Unatin, LLC have many years of experience representing those harmed as a result of errors in interpreting or communicating radiology results. Our lawyers have recovered significant damages resulting from mistakes involving radiology examinations like the following:
- Communication failures caused a 2-year delay in diagnosis and treatment of a 3 cm pelvic mass representing recurrent endometrial adenocarcinoma in a 55-year-old woman. The mass was identified on CT scans, but the findings were not communicated to a treating physician until the tumor doubled in size and spread inside the pelvis.
- A patient in his 50’s died of sudden cardiac death from cardiac neurofibromatosis 2 ½ years after signs of the disease were reported on a CT scan performed in the emergency department for a cough and fatigue;
- A 60-year-old woman died from advanced lung cancer due to a one-year delay in diagnosis of a lung mass found on a CT angiogram ordered to evaluate lower extremity vascular disease;
- A 47-year-old man died as a consequence of delayed diagnosis of an abdominal germ cell tumor due in part to a radiologist’s failure to provide a differential diagnosis or recommendation for follow up;
References
Brady, Adrian P. 2016. “Error and Discrepancy in Radiology: Inevitable or Avoidable.” Insights Imaging 171-182.
Busby, Lindsay P. 2018. “Bias in Radiology: The How and Why of Misses and Misinterpretations.” RadioGraphics 236-237.
Hanna, Tarek N. 2018. “Effect of Shift, Schedule, and Volume on Interpretive Accuracy: A Retrospective Analysis of 2,.9 Million Radiologic Examinations.” Radiology 205-212.
Lee, Cindy S. 2013. “Cognitive and System Factors Contributing to Diagnostic Error in Radiology.” American Journal of Roentgenology 611-617.
Pinto, Antonio. 2010. “Spectrum of Diagnostic Errors in Radiology.” World Journal of Radiology 377-383.
Tack, Dennis. 2019. “Missed Lung Lesions: Side-by-Side Comparison of Chest Radiography with MDCT.” Diseases of the Chest, Breast, Heart and Vessels 17-26.
ACR PRACTICE PARAMETER FOR COMMUNICATION OF DIAGNOSTIC IMAGING FINDINGS https://www.acr.org/-/media/ACR/Files/Practice-Parameters/CommunicationDiag.pdf