Errors in multidetector row computed tomography

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Jan 28, 2015 - ETHICS AND FORENSIC RADIOLOGY. Errors in multidetector row computed tomography. M. A. Mazzei1 · L. Volterrani1. Received: 28 January ...

Radiol med DOI 10.1007/s11547-015-0558-5

ETHICS AND FORENSIC RADIOLOGY

Errors in multidetector row computed tomography M. A. Mazzei1 · L. Volterrani1 

Received: 28 January 2015 / Accepted: 8 June 2015 © Italian Society of Medical Radiology 2015

Abstract Multidetector row computed tomography (MDCT) represents the technique of choice for the majority of pathologies today and is responsible for the majority of diagnoses. However, despite the low number of studies dedicated to errors in MDCT, CT reporting seems especially prone to generating errors and errors are an inevitable part of MDCT practice. Most of these arise during image interpretation but, differently from other radiological techniques, the awareness of radiologists regarding technical CT aspects and pathologies substantially contribute in generating errors, in particular because CT technology expands rapidly and radiologists do not routinely receive specific and appropriate training for its use and because CT examinations are not the same for each patient and each pathology and the choice of the most appropriate CT examination (including the dose exposure to the patient) presumes a very large awareness from radiologists. This review is aimed at increasing awareness regarding the type of errors in MDCT and in particular to also highlight technical and procedural errors. Keywords  Multidetector row computed tomography · Medical error · Diagnostic error · Dose CT

* M. A. Mazzei [email protected]; [email protected]; [email protected] 1



Department of Medical, Surgical and Neuro Sciences, Diagnostic Imaging, Azienda Ospedaliera Universitaria Senese, University of Siena, Viale Bracci 10, 53100 Siena, Italy

Introduction The medical error, interpreted as an error in one of the phases of the diagnosis and treatment process, represents one of the main causes of death today [1]. In particular, errors in imaging may lead to suboptimal treatment in cases of failure to recognise a pathology or to unnecessary hospital admission or surgery in case of a false-positive diagnosis [2]. The main reason for studying medical errors is to try to prevent them and the essential condition to prevent medical errors is the precise awareness of each problem, both in terms of identification of the critical point and in terms of analysis of the causes of the error. In radiology, errors can be more complex than in other fields of medicine, because they can arise from an inappropriate utilisation of the diagnostic technique or equipment (CT, MR, US system, etc.), which evolve rapidly with technological developments, requiring a constant update by radiologists. However many errors in computed tomography (CT) are not recognised as such because they do not produce a legal effect and on the other hand, the detection of errors in CT is in proportion to knowledge of radiologists. This review is aimed at increasing awareness regarding the type of errors in multidetector row computed tomography (MDCT) and in particular to also highlight technical and procedural errors. Error: what does it mean in radiological practice today? The Institute of Medicine defines an error as “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim”; however, other definitions of error are present in medical literature [3]. In addition, medical errors are defined as “mistakes made in the process

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of care that result in or have the potential to result in harm to patients”. Mistakes include the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. These can be the result of an action that is taken (error or commission) or an action that is not taken (error of omission) [4, 5]. In diagnostic activity, an error generally occurs as a consequence of inappropriate organisation, management processes (latent error) or in the perception or interpretation of diagnostic images (human error) [1]. Radiological errors in daily clinical diagnostic practice occur at a rate of about 30 % and errors that arise in relation to CT constitute the bulk of such errors; in particular McCreadie and Oliver, in a study of 222 patients, reported 256 errors, of which 159 (62 %) arose in relation to CT examination [6, 7].

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number of CT examinations, but also in terms of both length of coverage and number of phases obtained while scanning (baseline, arterial, venous and late phases) [10]. However, despite the importance of MDCT there is little diffusion of standardised and shared CT examination protocols so radiological malpractice in using this technique and the possible errors that could originate are many and from different aspects of its use (Table 1). Moreover, MDCT technical equipments are very different in terms of slices, dose exposure and diagnostic possibilities so that a lot of errors or a suboptimal use of the CT machine can occur if the radiologist is not experienced about the scanner used.

Type of error in MDCT Multidetector row computed tomography: the titan of diagnostic imaging Medical imaging is an essential tool for making often definitive diagnoses today, and MDCT is responsible for the majority of these diagnoses. It has become the investigation of choice in the workup of trauma, nontraumatic thoracic and abdominal emergency, oncologic patients and thoracic pathologies thanks to its high diagnostic accuracy, fast execution of examination and wide availability in public and private healthcare centres [8, 9]. This large diffusion has two main consequences: first MDCT is not a niche technique but a technique routinely utilised by the majority of radiologists (even if they have not received specific and appropriate training for its use) and furthermore a dosimetric consequence, leading to about 80 % of medical absorbed dose to the entire population, because of an increase not only in the absolute

Table 1  Errors in MDCT Errors in exam recommendation Errors in exam execution • Acquisition parameters (collimation, reconstruction interval, field of view, etc.) • Anatomical volume to be covered • Diagnostic modality (spiral, axial, distention of viscera) • Dose exposure to the patient Observer errors • Perceptual errors (scanning and recognition) • Decision-making errors Exam interpretation Medical report organisation • Failure to suggest the next appropriate procedure • Failure to communicate in a timely and clinically appropriate manner MDCT multi detector computed tomography

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Unappropriated CT examinations A more common error regarding CT is the appropriateness of its use. Both clinicians and radiologists should be involved in choosing the most appropriate diagnostic imaging for each patient and each pathology. In particular, both radiologists and clinicians should evaluate the risk–benefit ratio of a CT examination, choosing a diagnostic examination which takes into account the smallest amount of dose exposure to the patient with equal diagnostic results. Furthermore, the clinicians and radiologists should know the previous diagnostic examination/s performed on the patients, the clinical history of the patient and any possible clinical contraindications to the administration of contrast media (if it is not possible to administer intravenous contrast media and the unenhanced CT examination is not useful for clinical suspicion, it is an error to suggest a CT examination). The process of “exam recommendation” is particularly important in pathologies where CT cannot offer the same results as other diagnostic techniques. For example, in the diagnostic evaluation of pelvic pathologies or focal liver lesions, magnetic resonance imaging (MRI) is generally more appropriate than CT, also for the absence of ionising radiation. So it could be an error to perform a CT examination for the characterisation of a pelvic mass in a woman, especially in the reproductive age, or a CT examination for the characterisation of a focal liver lesion detected at US examination, especially in a young girls, even if both setting (for example emergency) and patient symptoms could influence this choice [11, 12]. In both these examples, radiologists’ errors when performing a CT examination instead of an MRI examination are related to the choice of an inappropriate radiological technique for the pathology’s assessment and for the undue dose exposure to the patient (Fig. 1). Furthermore, radiologists’ errors in performing a CT examination instead of an MRI

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Fig. 1  Errors in exam recommendation: Contrast-enhanced (a) and unenhanced CT (b) axial images of pelvis performed after US examination for a clinical suspicion of sigmoid diverticulitis in a 30-yearold woman with a history of acute left lower quadrant pain: both the contrast-enhanced and unenhanced CT showed a left adnexal mass, slightly hyperdense upon unenhanced CT image (white arrows). A MR examination performed after CT allowed the diagnosis of endometriosis showing the haematic component on T1 gradient echo image (c). In this clinical case, radiologists’ error in performing CT examination instead of MR examination was related both to the choice of an inappropriate radiological technique for the pathology’s assessment and for the undue dose exposure to the patient

examination can be also specifically related to a technical issue, for example in the diagnostic evaluation of an oral cavity pathology in presence of dental amalgam (Fig. 2).

Fig. 2  Errors in exam recommendation: Contrast-enhanced CT (a) and contrast-enhanced MR (b) axial images performed in a patient with a tumour of oral cavity (white arrows). The MR examination allows a better visualisation of the lesion (white arrow) in comparison with CT examination affected by amalgam artefacts. In this clinical case, radiologists’ errors in performing CT examination instead of MR examination were due to the choice of an inappropriate radiological technique and specifically related to a technical issue

Errors in exam execution Errors in exam execution are more common in MDCT examination than in any other diagnostic technique, both because of the complexity of the CT technique and because of the multiple variables that can influence the choice of the different technical parameters for each CT examination. Radiologists are responsible for the technical aspects of the CT examinations, and in particular they

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should personally choose, for each CT examination, any CT acquisition parameter (collimation, reconstruction interval, field of view, etc.). For example, in performing a high resolution CT examination of the thorax, some CT technical parameters are essential: the use of thin sections (0.5–1.5 mm), a high resolution algorithm for the reconstruction of images, the smallest field of view (FOV) that will encompass the lungs, and finally it is essential to obtain the HRCT images during a suspended full inspiration. However, radiologists should be also able to complete the HRCT examination with an expiratory or postexpiratory scan (for example to confirm the presence of an obstructive airway disease) or to decide when the HRCT examination should be performed using prone scanning (for example for differentiating early lung fibrosis from depend lung density). Radiologist is also responsible for the dose exposure to the patient that should be the smallest to obtain useful images on a quality level to perform a diagnosis and consider the type of patient and the kind of pathologies to perform a CT examination tailored both to the patient and the specific pathology characteristics. Regarding this issue, it is important for radiologists to know the technical possibilities of CT machines to reduce the dose exposure to patients, for example the adaptive statistical iterative reconstruction algorithms. This is particularly important in young patients or in oncological patients with a good overall survival. For example, it is totally different to perform a CT examination on a young patient suffering from an Hodgkin lymphoma (HL) that has a 5-year overall survival of 96.6 % presenting the possibilities to eventually develop a radiation-induced cancer in their remaining life. On the other hand, it is totally different to perform a CT examination on a 65 years old patient suffering from an inoperable lung cancer where both the poor prognosis of the neoplastic disease and the age of the patient are not sufficient to warrant a survival that will eventually develop into a radiation-induced cancer in their remaining life. Furthermore, they should personally choose the anatomical volume to be covered in relation to the clinical suspicion (for example, in clinical suspicion of ovarian cancer, a CT examination should cover the entire abdomen and thoracic bases and be performed with a very thin collimation, even if the clinicians have only requested a pelvic CT examination, in order to depict and localise small lesions of peritoneal carcinomatosis and to eventually verify the presence of neoplastic pleural effusion), choose the appropriate diagnostic modality (for example, for a thoracic CT examination radiologists should choose to perform an high resolution CT examination or not based on clinical suspicion or they should consider some additional modality to improve the CT accuracy in some neoplastic diseases, like gastric distention in gastric cancer CT staging), and finally choose the number of CT acquisition

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Fig. 3  Errors in exam execution: 2D multiplanar reconstruction on coronal plane of a contrast-enhanced CT examination in two different patients during a follow-up for Hodgkin lymphoma: the dose exposure to the patient was 629 DLP (mGY-cm) in the CT examination reported in (a) whereas resulted in 2793 DLP in the CT examination reported in (b) without a significative difference about the image quality. In this clinical case, radiologists’ errors in performing the CT examination reported in (b) were related to an incorrect choice of CT parameters leading a high dose exposure to the patient

phases and anatomical volume of each phase (in order to reduce the dose exposure to the patients) [13–16] (Figs. 3, 4, 5). Observer errors In medical imaging, 80 % of errors are attributed to perceptual errors [8]. If perceptual errors occur, the disease can be misdiagnosed. To address this type of error, retrospective analysis of previous errors as well as conducting double reading (image is read independently by two people) is effective [17]. The perceptual errors, i.e. sensory errors, are the results, as common sense would have it, of the failure to visually register an objective, abnormal radiological finding. Perceptual errors, described by Kundel et al. classification as a scanning error or a recognition error, are included together with decision-making errors into observer errors (see Table 1) [18]. Both these types of error (scanning and recognition) result in a misdiagnosis (missed lesion or failure of abnormality detection). A scanning error is the result

Radiol med Fig. 4  Errors in exam execution: 2D multiplanar reconstruction on coronal plane (a) and axial image (b), at the level of right renal pelvis, of a contrastenhanced CT examination in a 22-year-old man after a motor vehicle accident. The radiologist correctly chose to perform an excretory phase CT limiting the anatomical volume to be covered at the right renal pelvis (c), because of the diagnostic suspicion of renal pelvis fracture. In this clinical case, the radiologist, limiting the anatomical volume to be covered in the CT excretory phase, significantly reduced the dose exposure to the patient

of failure of the radiologist to fixate in the area of the lesion whereas a recognition error involves fixating in the territory of the lesion yet failing to detect the lesion. Failure of abnormality detection in film reading (perceptual errors) is subject to psychophysiological factors of human visual perception [19]. In particular, perceptual errors, in general, are related to multiple psychophysiological factors, including level of observer alertness, observer fatigue, duration of the observation task, any distracting factors, conspicuity of the abnormality, and many other factors [20]. In MDCT examination, the high number of CT images substantially contributes to the perceptual error; however, the reduction of number of images (i.e. image retro reconstruction with a thicker slice) should be discouraged because of the reduction of the CT diagnostic capabilities. An additional source of error results from the influence a radiology report has over another radiologist. This type of perceptual error, called an alliterative error, occurs because the radiologist reads the old report before looking at the images, if the first radiologist missed it, the next radiologist is likely to miss it as well [21]. For both these types of errors (scanning and recognition), there is no significant difference between CT and other diagnostic techniques with the exception of the overloaded of images in CT studies, so generally the perceptual error is due to the lack of visualisation of all the images obtained; in particular in CT examination, the anatomical area where the lesion is present is always represented but not visualised by the radiologist, whereas in an

ultrasound examination the area with the lesion cannot be evaluated by the radiologist (unless it was represented on an US image!); moreover, in a CT study quite all pathologies can be observed even if the goal of CT examination is completely different (i.e. a small ground glass lung adenocarcinoma in a CT examination performed for a clinical suspicion of pulmonary embolism) [22]. One of the most common scanning errors in CT examination is the lack of visualisation of bone lesions, for example during a staging CT examination. The increased complexity of CT studies means that they take longer to review, even if, in recent years, for most radiologists, the time available to report these studies has remained static or reduced, and the time pressure this creates may lead to elements of the examination being omitted, such as a meticulous review of images on bone windows. However, also renal, ureteral, pancreatic and breast lesions are often missed (Figs. 6, 7). Scanning errors also play an important role in the interpretation of an abdominal trauma CT. Clark West and his colleagues identified three patterns of perceptual errors in interpreting 254 abdominal trauma CTs. These included: (1) missed vascular contrast extravasation; (2) missed hemoperitoneum; (3) missed right retroperitoneal and/or adrenal haemorrhage, whereas isolated errors included: (1) missed sentinel clot and “mesenteric triangles” (fluid trapped between the leaves of the mesentery) which were suggestive of a bowel injury; (2) missed oral contrast extravasation due to bowel perforation [2].

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or conversely realise a false-positive diagnosis. This can happen, for example, in the interpretation of an abdominal trauma CT when the incorrect position of the arms or the presence of medical devices can realise linear beam hardening artefacts that can mimic liver or spleen laceration (Fig. 8). As described above, a technical error is also associated in the majority of decision-making errors in CT study, and this underlines the complexity of the error mechanism in CT (Fig. 9). Errors in exam interpretation

Fig. 5  Errors in exam execution: a thorax CT scan (a) and a CT scan optimised for the study of the solitary pulmonary nodule discovered on the right upper lobe (b, collimation 0.625 mm, field of view: 10 cm, acquisition modality: axial, kernel: bone plus, kV140, mA 330). This clinical case demonstrates the significant difference achievable about image quality in the characterisation of pulmonary nodule using a dedicated CT technique (in this clinical case a small lung adenocarcinoma measuring 10 mm)

Besides perceptual errors, decision-making errors are also included into observer errors. The decision-making error, according to Kundel definition, is due to the incorrect interpretation of a malignant lesion as a normal structure. This definition can be accepted for some radiological techniques (radiography or ultrasound) but it should be revised for CT examination. In particular, an incorrect interpretation of a malignant lesion as a normal structure is not common in CT whereas it is more common to fail a lesion interpreted as an artefact or a benign lesion

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An interpretation error, i.e. a cognitive error, is the result of the failure to correctly interpret a perceived radiological abnormality because of insufficient experience or knowledge or an underestimation of one or more other signs that would have prompted the correct diagnosis. There are many reasons why radiologists make errors in exam interpretation, the most important being the vastness of the pathology and the need to know the clinical presentation, pathology and treatment of the majority of pathologies both to realise a correct interpretation of the images (and then to perform a correct diagnosis) and to produce an appropriate medical report (meaning a useful report for the clinical and therapeutic management of that pathology). Examples of errors in exam interpretation are the lack of an appropriate evaluation of the response to therapy in a restaging CT performed on an oncologic patient without appropriate criteria or the lack of a correct diagnosis of non-occlusive mesenteric ischaemia in a patient with a suitable clinical suspicion [23–25]. However, the exam interpretation error could be reduced, at least partially, if the correct diagnostic predictions based on clinical information were suggested. A systematic review claimed that appropriate clinical information improves the reports of diagnostic examinations [26], such as CT [27, 28]. Increases in false-positive rates by providing clinical information have also been reported [29] but this appears to be due to interpretative errors, rather than perceptual errors, since clinical information improved the detection of small lesions in another study [30]. Thus, clinical information seems to play a crucial role in detecting abnormal findings. However, even with appropriate clinical information, reading errors may still occur if correct predictions are not made. Making diagnostic predictions from specific clinical information has improved the correctness of radiographic reports [30], visual examination [31] and electrocardiography [32] and in a recent study Suzuki and his colleagues [33] report that making correct diagnostic predictions based on specific clinical information, more than clinical information itself, influences the accuracy of reading CT scans too.

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Fig. 6  Observer errors: a contrast-enhanced CT examination performed in a 60-year-old woman during a follow-up for a previous adenocarcinoma of the colon showed an urothelial carcinoma of the left upper urinary tract (a and b) missed by the radiologist and dis-

covered 2 years later because of the appearance of recurrent haematuria (c and d). In this clinical case, the radiologist committed a scanning error

Medical report organisation

obtain or confirm the diagnosis. Failure to suggest the next appropriate procedure is another “Achilles’ heel” of medical reporting by most radiologists, because it is really difficult to have good knowledge of all specialities in medicine today [5]. Clinicians (ordering physicians) should also know the next appropriate procedure to suggest when an abnormality cannot be characterised on the imaging study they originally requested. However, if the patient becomes a plaintiff in a lawsuit against the ordering physician, the radiologist can almost be assured that the ordering physician will claim ignorance as to what to do next because the radiologist did not specify what to order next [3]. The American College of Radiology (ACR) “Practice Guideline for Communication of Diagnostic Imaging Findings” states that “follow-up or additional diagnostic studies to clarify or confirm the impression should be suggested when appropriate” [34]. The last important aspect of medical reporting is the communication of this in a timely and clinically appropriate manner. In addition to rendering an official interpretation (a final written report), the

The CT report is another important point of the medical diagnosis process and it assumes particular importance in CT examinations where the findings that radiologists could report are usually more than in any other radiological technique and often crucial for the management of the patient. In general, the radiological report should represent and substitute the discussion about the clinical case between the radiologist and the clinician. It should be clear and concise and should firstly report the essential data about the found pathology and secondly any other collateral data that are not strictly related to the main pathology but that could also be important for the patient [34]. Radiologists should always report their diagnostic impressions because the lack of a diagnosis in a CT report does not exclude a possible legal consequence for radiologists. If a precise diagnosis is not possible with the CT examination alone, radiologists should write the most likely diagnostic impression and suggest the next procedure to

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Fig. 8  Observer errors (decision-making error): a contrast-enhanced CT examination performed in a 55-year-old-man after an high-energy road traffic accident. The scout view (a) shows the incorrect position of the arms (both on the same plane) that prevents an optimal evaluation of a liver injury (b). In this case, the radiologist could commit a decision-making error

Fig. 7  Observer errors (scanning error): a contrast-enhanced CT staging examination performed in a 65-year-old-woman suffering from a breast cancer showed multiple liver metastasis (a); the breast lesion was also reported (b, right breast). The breast lesion was missed at a CT examination performed 2 years before (c) for a characterisation of a pancreatic lesion resulted in a low grade GIST. In this case, the radiologist committed a scanning error

radiologist is responsible for communicating these findings directly to the referring physician. Errors in communication are the fourth most frequent allegation against radiologists in medical malpractice claims and failure to communicate is one area in which the radiologist can take a direct role in reducing the risk of malpractice [35, 36]. When communication is not documented, the radiologist risks losing a lawsuit when there

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are adverse or unexpected clinical outcomes. Documentation should also include the date, time, name of the person spoken to, and the nature of what was discussed [37].

Conclusion MDCT represents the technique of choice for the majority of pathologies today and is responsible for the majority of diagnoses. Despite the low number of studies dedicated to errors in MDCT, CT reporting seems especially prone to generating errors [2, 9, 26–28, 33, 38, 39]. The reasons for the previous sentence are numerous and from different origin: (1) the volume of imaging procedures has accelerated enormously in recent years; (2) current CT studies frequently generate a mean value of 700–800 images or more; (3) for most radiologists, the time available to report these studies

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Fig. 9  Observer errors (decision-making error): a contrast-enhanced CT staging, performed in a 66-year-old-man suffering from a lung cancer on the right upper lobe (a), shows a strict artefact in the supe-

rior caval vein that prevent the correct evaluation of the mediastinal lymph nodes in both stations 4R and 2R (b, c and d). In this case, the radiologist could commit a decision-making error

has remained static or reduced, in spite of evidence showing that reporting errors increase as case throughput increases and reporting time per examination reduces; (4) CT technology expands rapidly and radiologists do not routinely receive specific and appropriate training for its use, even if technical errors represent a large part of errors in MDCT; (5) finally, CT examinations are not the same for each patient and each pathology and the choice of the most appropriate CT examination (including the dose exposure to the patient) presumes a very large awareness from radiologists. In conclusion, errors are an inevitable part of MDCT practice. Most of these arise during image interpretation but, differently from other radiological techniques, the awareness of radiologists regarding technical CT aspects and pathologies substantially contribute in generating errors. Retrospective analysis of cases where an error is felt and continuous clinical and technical updates both have an educational benefit and should be considered an essential tool for improving CT diagnosis [40].

Acknowledgments  The Authors thank Ms. Julia Hassall for reviewing the English language and Dr. Susanna Guerrini for editorial assistance in the manuscript and images preparation. Conflict of interest  The authors declare that they have no conflict of interest. The submission of this manuscript for publication has been approved by all the authors and by the appropriate authority at the Institution where the work was carried out. Ethical approval  This article does not contain any studies with human participants or animals performed by any of the authors.

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