Report Finds Radiologists to Blame for Missed Diagnoses

By John Palmer

A new report from medical liability insurer Coverys indicates that radiologists are involved in an alarmingly high number of diagnosis-related insurance claims, and that 80% of missed diagnoses are alleged to have resulted from the misinterpretation of clinical tests.

The Red Signal Radiology Report reviews five years of Coverys’ closed claims to identify major risk factors, illuminate warning signals and safety vulnerabilities within radiology practices, and provide evidence-based recommendations to help radiologists proactively avoid patient harm.

Findings revealed that radiologists were second only to general medicine practitioners in diagnosis-related malpractice claims. Of the radiologists’ total claims, 80% were “alleged” to have been related to misinterpretation of clinical tests, according to the report’s author Robert Hanscom, vice president of business analytics for Coverys.

“Claims alleging errors in radiology practices are common in medical professional liability claims,” Hanscom wrote. “Such errors can have a profound effect on the patients impacted from the delay or incorrect management of a clinical diagnosis. These misdiagnoses can be life-threatening or life-altering—in fact, Coverys data shows that patient death is the highest clinical outcome in radiology claims.”

With advances in technology, there is an increased demand for radiology services, creating an imbalance of workload demand and workforce resources that can lead to diagnostic inaccuracies and impact patient safety, says Annemarie Provencher, RN, senior risk specialist at Coverys.

According to the Radiologic and Nuclear Medicine Studies (RSNA), an estimated 3.6 billion radiological tests are performed annually around the globe.

With the rising demand and the sheer volume of tests performed, radiologists may be compelled to “interpret and report a large volume of studies quickly without adequate time to fully consider alternate diagnoses,” Provencher says. “In addition to diagnostic inaccuracy, other potential patient safety concerns include the wrong procedure being performed or studies being performed on the wrong patient or the wrong site, handoff communication breakdown, and unnecessary radiation exposure. Radiologists should educate and involve patients in the diagnostic process, encouraging them to take an active role in their care. An informed patient can assist the healthcare team, reducing the likelihood that a medical error will occur, and make sure that every radiology study performed carries more benefit than risk.”

Changing responsibilities

Over the last 20 years, Provencher says, radiologists have assumed increased responsibilities in utilization management, quality of care, patient safety, and information management. Advances in imaging technology have expanded their diagnostic capabilities to make them a vital part of the healthcare team.

“It is important that radiologists integrate into the diagnostic team, coordinating and collaborating throughout the patient’s entire episode of care,” she says. “They can help decide what diagnostic images need to be performed and share their interpretation with the healthcare team to help determine the best treatment options for the patient and whether additional testing is needed. Radiology’s role is no longer just to capture diagnostic images and read the images correctly, but rather guide the entire treatment process from diagnosis to coordinating best care.”

The interpretation of a radiologic study is not always black or white, says Provencher. In some cases, a radiologist can give a conclusive diagnosis, but in most cases, the final interpretation is influenced by variables such as the patient’s past medical history, previous imaging, and current clinical condition.

Causative factors that can influence diagnostic accuracy typically fall into two categories: system issues and cognitive/perceptual errors. System issues include excess workload, visual and mental fatigue, lack of experience or knowledge, suboptimal reading and reporting environments (e.g., poor lighting conditions), distraction due to frequent interruptions, constant repetition of similar tasks, unavailability of previous studies for comparison, and inadequate clinical information.

Cognitive and perceptual errors, meanwhile, can involve biases and failed heuristics, also known as mental shortcuts. An example of a common cognitive bias in radiology is “satisfaction of search,” Provencher says. “This occurs when a radiologist finds an abnormality and assumes the search is over, which can cause a missed opportunity for identifying additional abnormalities or incidental findings,” she adds. “The adoption of standard imaging protocols and the use of clinical decision support tools may reduce the likelihood of error by prompting radiologists to consider other diagnoses and resist the biases and assumptions that lead to diagnostic errors.”

The report also claims that among radiology claims alleging diagnostic failure, cancer diagnoses are the most frequent, with breast, lung, pancreatic, and ovarian cancers getting missed most frequently. Lack of follow-up on abnormal test results, such as from radiology or primary care, appears to be the culprit, says the report.

Radiology reports often recommend follow-up imaging to monitor potentially malignant findings, for further diagnostic identification, or to review the status or resolution of potentially serious diseases, Provencher says. Failure to comply with these recommendations can result in harmful delays in treatment or diagnosis.

“Lack of radiology recommendation follow-up can be due to system errors such as the referring provider failing to order follow-up testing, patients missing scheduled tests or visits, or the provider not receiving the imaging results or failing to read the report,” she says. “Implementation of results notification and follow-up tracking systems are important risk strategies that can help increase the number of patients who get the follow-up that radiology reports recommend.”

Poorly written or ambiguous language in a radiology report can also lead to diagnostic failures, she says—such as misunderstandings or incorrect impressions on the part of the referring provider.

“Depending on the clarity of the report language, there may be considerable differences in how the referring physician interprets the intended message from the radiologist that may lead to a misunderstanding of follow up recommendations,” says Provencher. “Radiologists can have a direct impact on communication of abnormal imaging findings by improving the quality and clarity of the written report. A well-crafted report consists of a comprehensive format, definitive language, meaningful impressions, and a concise differential diagnosis with clear, time-specific follow-up recommendations when applicable.”

The report offers several recommendations to help reduce diagnostic errors when considering radiologic information, including the following:

• Use decision support tools and standard treatment protocols to manage workflow and meet patient needs.
• Develop criteria to determine whether a second read of a film must be performed, including the time frame for completion. The process should include confirmation back to the radiologist that the second read has been received.
• Develop report templates that require specific elements, such as problems suspected, problems that have been ruled out, and probable diagnosis and recommendations. Discourage use of disclaimers or language such as “dictated but not read.”
• Use clear language, avoiding interpretive phrases such as “cannot rule out,” “consistent with,” or “likely represents.”
• Incidental findings and their recommendations should be separated from the rest of the report or highlighted within the report to draw the eye.
• Apply appropriate use criteria and other guidelines at the point of order to ensure the necessary studies are done for a specific clinical condition.
• Implement checklists that can help circumvent cognitive biases and decrease reliance on memory.
• Implement formal quality improvement methods, practice changes, or other performance improvement processes.
• If teleradiology is practiced in the facility, conduct regular testing for film and transmission quality.
• Revisit peer review practices to ensure they address how to measure and communicate periodic evaluation of clinical outcomes and compliance with established quality indicators, and when performance may warrant closer review.

“Radiologists play an ongoing and critical role in the delivery of an accurate patient diagnosis, and it is paramount that they are actively integrated into the diagnostic team,” the report concludes. “Examination of radiology claims data can help signal potential vulnerabilities during the diagnostic process of care. In the long run, putting best practices in place will help improve patient outcomes, reduce malpractice exposure, and address key quality measures that align with MACRA, MIPS, and AAPM payment model metrics which could have a favorable impact on reimbursements.”

John Palmer is a freelance writer who has covered healthcare safety for numerous publications. Palmer can be reached at safetyjohn@yahoo.com.