Patient Safety Tip of the Week Archive

What’s New in the Patient Safety World

November 2021

When a Radiologist Recognizes He Committed an Error

We’ve done many columns on the importance of disclosure and apology when a medical error occurs. But most of those columns deal with errors by clinicians providing direct care to patients. What about errors that are made by physicians who may have no direct interaction with patients, for example, radiologist and pathologists?

Recently, it was asked “When you, as a radiologist, come across a significant finding (or findings) that you missed, what would you do or not do next and why?” (Lexa 2021). Answers from all four of the radiologists responding emphasized doing what’s best for the patient. All would immediately contact the ordering clinician and make them aware of the error. Some noted they would speak to the patient themselves if the error had no clinical consequence. Most would also discuss the error with their risk manager and were concerned about the particular wording that would be used in any communication with the patient.

We especially liked the response from Johns Hopkins’ David M. Yousem: “Right it, own it, learn from it, share it.” “Right it” meant calling the clinician and correcting reports with addendums, putting the patient’s well-being first. “Owning it” meant admitting the error and moving forward with humility. He would also make a call to risk management and “state the facts”. “Learn from it” meant trying to understand why the oversight occurred (eg. blind spot? distraction? fatigue? cognitive bias?, etc.) and making changes to avoid mistakes in the future. And “sharing it” meant helping others understand how such an error happened so they don’t make similar mistakes.

The scenario given with the above question was one where the radiologist reads a CT scan and finds significant pathology that needs emergent attention from the referring physician. But on reviewing the current study with one done just a few days earlier, he/she realizes he/she had missed the significant finding on that prior CT scan.

We’ve certainly seen cases where the timeframe between imaging studies is not so acute. Perhaps the most common scenario is when a patient has a CT scan that shows a large mass or an obvious metastatic lesion and review of a chest x ray or CT scan done a year ago actually shows the abnormality, albeit much smaller and more obscure at the time. In those cases, we always recommend that the patient (or family) be informed of the missed finding. Transparency is of the utmost importance. Such disclosure must be done with an apology that is truly sincere. Who makes the disclosure to the patient or family? Most often it is done with the clinician who has an established relationship with the patient. But that is not always possible. Sometimes a hospitalist has just begun caring for the patient and has no such established relationship. So, sometimes it is the medical director that delivers the disclosure. The radiologist who missed the original abnormality should be there at the time of disclosure. Showing contrition and concern for the patient helps the patient and family understand that we are human and make mistakes. We’ve certainly seen cases where patients and families have chosen not to take malpractice actions in that scenario. It is much easier to sue an individual or entity that does not “have a face”.

Unfortunately, most physicians are poorly prepared to such disclosure and apology. We strongly recommend that all healthcare organizations train their physician staffs on how to deal with such instances. There is nothing more powerful that having a physician who has been involved in such incidents share with others the thoughts and feelings he/she experienced in recognizing the error and communicating with the patient and family. Most often, that physician felt a certain amount of relief after the disclosure and it helps others understand that disclosure and apology may be the first step in a physician successfully dealing with his/her own infallibility.

See our many columns listed below for details on disclosure and apology and also on “communication and resolution” programs.

Some of our prior columns on Disclosure & Apology:

July 24, 2007 “Serious Incident Response Checklist”

June 16, 2009 “Disclosing Errors That Affect Multiple Patients”

June 22, 2010 “Disclosure and Apology: How to Do It”

September 2010 “Followup to Our Disclosure and Apology Tip of the Week”

November 2010 “IHI: Respectful Management of Serious Clinical Adverse Events”

April 2012 “Error Disclosure by Surgeons”

June 2012 “Oregon Adverse Event Disclosure Guide”

December 17, 2013 “The Second Victim”h

July 14, 2015 “NPSF’s RCA2 Guidelines”

June 2016 “Disclosure and Apology: The CANDOR Toolkit”