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What’s New in the Patient Safety World

November 2022

Reading Too Many Images



It might sound like stating the obvious. But a new study (Ivanovic 2022) from a large academic medical center showed that diagnostic errors on reading neuroradiology studies increased with increasing volume during shifts.


The researchers looked at attending physician errors in CT and MRI reports from their Neuroradiology Quality Assurance database for the years 2014-2020. The found 654 reports with diagnostic errors. There was a significant difference between mean volume of interpreted studies on shifts when an error was made compared with shifts in which no error was documented (46.58 vs 34.09). 59.6% of errors occurred in the emergency or inpatient setting. 84% were “perceptual” errors (where a finding was missed), as opposed to “interpretive” errors (where an abnormality was identified but misinterpreted). Moreover, 91.1% of the errors were clinically significant.


Errors were detected most often on brain MRI (25.4%), head CT (18.7%), head/neck CTA (13.8%), and spine MRI (13.7%). Categories of errors were: vascular 25.8%, brain 23.4%, skull base 13.8%, spine 12.4%, head/neck 11.3%, fractures 10.2%, other 3.1%.


The authors conclude there is a need for national guidelines establishing a range of what is a safe number of interpreted cross-sectional studies per day. They note that it would be useful to understand how factors like shift length, interruptions, staffing levels, etc. contribute to higher error rates. They also question how cognitive biases contribute to these errors.






Ivanovic V, Paydar A, Chang Y-M, et al. Impact of Shift Volume on Neuroradiology Diagnostic Errors at a Large Tertiary Academic Center. Academic Radiology 2022;  Published September 27, 2022






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