iRADiX

Having realized that an error was made …What is your next step?

“To err is Human”

Can we safely apply this principle to our Practice and expect protection against the errors made in our reports?

A search for Medical errors in Medscape provides you mind-boggling 4284 references. These errors include contribution not just from Radiology also from other branches including paramedics errors.

Dr. Keshav Kulkarni in his 4 part blog ‘to err is human’ has excellently dealt in detail, various causes and lacunae that are responsible for the errors and how to prevent the same along with remedial measures.

My request to the fresh members of Iradix, is…... please go through his blog.

Errors in Radiology Practice are common and I am sure All of us make some mistake at one time or other, since all of us are in the Ever learning process through out our career.

It is well known that preventable medical mistakes are one of the leading causes of death in the United States Medical errors account for more deaths in America than breast cancer, AIDS or car accidents annually. Though no statistics are available for India it must be equally true for our country also

Once you realize that mistake has been made in reporting…

How do you convey this to the patient?

In case you pick up the error made by another Radiologist how do you proceed?

I shall narrate ‘situations’ shared by some Radiologists. I strongly recommend to all the radiologists in their respective cities, towns to mutually exchange any mistakes made in reporting so that everyone is benefited and can avoid committing the similar mistakes

The situations I am talking are all in relation to Ultrasound reports. These situations can happen to any radiologist.

Situation 1

A young unmarried girl of 20 yrs age with history of irregular periods, referred for acute abdominal pain for USG abdomen study. Her Urinary bladder was over distended and she was restless and screaming due to pain and was yelling at everyone in the department. The radiologist did not lose any time and called her in due to the emergency nature and did a quick scanning and surprisingly no abnormality was detected. Report was given as normal study and promptly informed the ref doctor. Of course trans vaginal scan can not be done since the girl is unmarried.

The girl subsequently never had any follow up scan and her parents noticed that she was putting on weight very fast and both the ref doctor and her parents advised her to eat less and do lot of gym exercises.

After 8 months this ref doctor called the radiologist and informed him that this particular patient had premature delivery. Her father was furious and argued that USG should have picked up the pregnancy 8 months back itself and that radiologist has erred.

since his unmarried daughter’s future is at stake, the father refrained.

What could have gone wrong here?

Probably the Early Gestational sac was compressed by the over distended urinary bladder and not clearly visible during scanning.

If only the girl underwent subsequent scanning probably pregnancy would have been confirmed.

Lesson learnt-

Whenever there is history of irregular periods, Do post void study and recheck the Uterus for Gestational sac.

Many times the early gestational sac (approx 4 to 5 Wks) gets compressed by the over distended urinary bladder and can not be appreciated.

Situation 2.

A freshly graduated Radiologist did an USG on a lady patient and diagnosed multiple gall bladder calculi. Patient underwent lap cholecystectomy and no gall stones were found.

Possibilities- Air pockets of duodenum might have been mistaken for gall stones

Or Sludge balls which were picked up and reported as calculi might

have disappeared by the time operation was undertaken

Lesson learnt-

Always gain enough experience under an experienced radiologist before independently

reporting.

Situation 3.

When an antenatal scan was done at 12-13 wks of gestation Twin pregnancy was reported.

When the patient came for targeted scan at 22 wks to the same scan center triplets were picked up. Of course the study was done by two different doctors. Patient is naturally upset that she has lost an opportunity for selective reduction.

More worries to the patient now regarding complications of triplet pregnancy. Always Remember majority of the patients are Doctors themselves by default, thanks to internet Medical knowledge

Lesson learnt-

Can mirror image artifact cause these kinds of confusion?

Doing an Obstetric scan is not a Childs Play

Situation 4.

On the 4th day of post lap cholecystectomy an aged lady patient developed jaundice and USG was done as an emergency at 11.00 pm, to find out the cause. USG report read... Normal gall bladder. CBD was dilated and showing a calculus.

Patient wanted to sue the surgeon telling that GB was not removed and the operation was a failure.

Now surgeon thought of putting a case on the Radiologist for the irresponsible report.

Just observe the Chain reaction!!!

Surgeon never wanted another sonogram from any other radiologists and straight had one Scintigram and proved that GB was indeed absent.

Fortunately for the radiologist …he has mentioned Post cholecystectomy status in the FILM but forgot to mention the same in the report in a hurry.

Lesson learnt-

If you do reporting in a hurry...Remember that You tend to commit major mistakes.

Late night scan reporting...be extra careful! (since you are exhausted after a busy day)

And do not forget to label in the film….. post hysterectomy status or post cholecystectomy status etc,

Whatever may be the reason …discomfort was caused to all the parties concerned.

Situation 5.

Both the patients have similar name and same initials

Both under went digital chest ray on the same day

The only difference is one had Koch’ lesion and the others was a normal study.

The films got exchanged during dispatch.

The one without Koch’s lesion underwent short course of ATT,

Though the radiologist is not at fault in this scenario… still he has to take the blame.

Lesson learnt-

Your responsibility does not cease even after signing the report!!

Here the blame goes to the system. i.e. style of functioning of the system right from the typist to front office staff to the dispatch clerk and finally to you and you alone.

Situation 6

Patient was referred for USG scrotum to rule out varicocele, as part of investigation for infertility. This radiologist prefers to do USG for scrotum in darkness as he says that generally patient is at ease if there is a little darkness otherwise pt is disturbed when the study is done under bright light. The only illumination radiologist gets is from the scan machine monitor. The study was completed for this patient and report was given as normal testicles with bilateral varicocele. (grade II)

The patient was referred to an urologist who felt that the patient in question is having only one testicle, and asked for a review of the scan .Review scan confirmed normal Right testicle and absent testicular echoes in left scrotal sac and left inguinal canal ( probably intra abdominal or congenital absence)

How that is our radiologist friend missed the un descended testicle in the first instance?

The reason is very simple.

1. Because the scan room was dark our radiologist friend failed to have a clear look at the scrotum (the basic step) and was approaching the single testicle that was present, from all angles and imagined that both testicles are present.
2. Further our friend failed to look for both testicles in a global cross section view.
   Radiologist was subjected to severe embarrassment.

Lesson learnt-

Never develop the habit of doing ultrasound scan in total or partial darkness (managing just with brightness emanated from scan machine)

Many a time one fails to do a proper physical exam and may even miss noticing the laparoscopic scars if any.

Darkness….Indeed injurious to your health!!!

Now coming to the point

Whenever you realize that you have committed an error the guilt starts building and it is just question of time it starts haunting you. You spend many sleepless nights. You start searching for all the available excuses.

You are at peace only when the problem gets solved.

Ok. Now that you realized that the error is made ….how do you communicate to the patient?

A few possibilities

1. you think you do not have any obligation to inform the patient since your report as a radiologist is simply based on shadows and many times you are helpless because of the limitation. This philosophy is nothing but Arrogance
2. Do not inform the patient. because you are scared of the various problems that may follow which you are not willing to face starting from mal practice litigation to losing trust in you, to even patient spreading the news to relatives and friends tarnishing your image.Remember…..The above fears in you become really TRUE only when you do not disclose the error by not disclosing the error you are taking an unethical step
3. You do not inform the patient because you are scared of present day super active electronic media be a TV or print media which you think are going to do a witch hunt. Grab this opportunity to explain to the media why, where and how things went wrong. Who knows……You may soon become a celebrity!!
4. Disclose the error to the patient and at the same time inform the referring doctor also and request him to Convince the patient. A very Justifiable action. Hats off to your moral courage!
5. Disclose the mistake to the patient, repent; be apologetic to both the patient and the referring doctor. Even go one step ahead and offer compensation in a mutual acceptable proposition. Indeed a commendable act!!

In case you pick up the error made by another Radiologist how do you proceed?

A few possibilities

1. Do not inform the concerned radiologist. Because it is none of your business. This shows that you are highly insensitive to basic professional ethics.
2. Since the radiologist in question is your opponent + enemy No-1 spread the news to all Sundry about the mistake So that the radiologist gets the information through some third person, by that time enough damage is done to your opponent. Don’t forget that the Earth is round and the same situation can bounce on you one day….
3. Do not lose time in promptly informing the Radiologist who has erred in his reporting about the mistake he made and asking him to apologize to the patient. An appreciable and noble act indeed, benefiting both the patient and the radiologist

I always wish that patients should have a sympathetic attitude when a doctor discloses an error and seeks an apology

I wish every patient reads the following as to what every doctor feels from the bottom of his/her heart. “My failures have been errors in judgment, not of intent.” -- Ulysses S. Grant

References:

1. Medical errors- the problem
2. Should we disclose harmful medical errors to patients? If so, How?
3. Apologies and Medical errors
4. Criminalizing Medical Errors: Does the Punishment Fit the Crime?
5. Disclosure of Unanticipated outcomes.