Which of the following in NOT an effective approach to identifying diagnostic errors?

1. Multidisciplinary conferences
2. Radiology-Pathology correlation
3. RADPEER*
4. Nonrandom peer review

• According to the article “Fundamentals of diagnostic error in imaging” by Itri et al., retrospective peer review processes such as RADPEER are not an effective approach to identify diagnostic errors.
• The remaining options are methods that can be used to identify diagnostic errors.

How many hours can be worked by residents in a continuous overnight call shift before there is a statistically significant increase in diagnostic errors?

1. 8
2. 10*
3. 12
4. 14

• According to a research project described in the article “Fundamentals of diagnostic error in imaging” by Itri et al., there is a statistically significant increase in major discrepancies after working 10 consecutive hours overnight. This corresponds to work shift length maximums described in other professions including truck drivers, pilots, and train operators based on the observation that errors increase after 9-10hours of continuous work.

Which of the following is an effective strategy to identify contributing factors when applied to analyzing diagnostic errors?

1. Failure modes and effects analysis
2. Value stream mapping
3. Pareto chart
4. Root cause analysis*

• Root cause analysis (RCA) in an effective strategy to identify contributing factors when applied to analyzing diagnostic errors. RCA includes 3 components: (a) consideration and identification of factors most directly associated with the event; (b) analysis and prioritization of these factors to plan the introduction of effective strategies to prevent them from recurring; and (c) introduction, management, and—when possible—dissemination of effective countermeasures.
• Failure modes and effects analysis is a quality improvement tool for evaluating a process to identify where and how it might fail and to assess the relative impact of different failures, in order to identify the parts of the process that are most in need of change.
• Value stream mapping is a Lean manufacturing or enterprise technique used to document, analyze and improve the flow of information or materials required to produce a product or service for a customer.
• A pareto chart can be used when analyzing data about the frequency of problems or causes in a process. This is a helpful quality improvement tool when there are many problems or causes and you want to focus on the most significant or those that would have the greatest impact.

What should a radiologist do when he identifies a missed sternal fracture on a chest CT interpreted by a resident overnight, and the patient has already been discharged?

1. Document the discrepancy in the final report
2. Call the ER but don’t document the discrepancy in the final report to protect the resident
3. Call the ER and document communication of the sternal fracture in the final report*
4. Send the case to the residency program director

• The radiologist should call the ER and document communication of the sternal fracture in the final report. This satisfies the ACR practice parameter on communication of significant changes between preliminary and final reports.
• Documenting the discrepancy in the final report and sending the case to the residency program director do not satisfy the ACR practice parameter on communication of significant changes between preliminary and final reports.
• There are instances in which documenting the discrepancy in the final report is an acceptable practice.

Which of the following is a recommendation for radiologists to reduce the risk of a malpractice claim?

1. Implement over-read and second-evaluation processes that occur on an ongoing basis with feedback given to radiologists*
2. Encourage the use of phrases such as“when appropriate” when making recommendations about follow-up imaging
3. Ensure that practices are using a random peer review process such as RADPEER to document errors rates
4. Avoid using teleradiology or nighthawk services to read overnight studies

• According to the Covery report, implementing over-read and second-evaluation processes that occur on an ongoing basis with feedback given to radiologists is a recommendation to reduce the risk of a malpractice claim.
• The remaining options are not recommendations to reduce the risk of a malpractice claim.

Which of the following is the best criteria for identification of peritoneal metastasis in patients with ovarian cancer?

1. Presence of ascites
2. Parietal peritoneal thickening
3. Small bowel wall thickening
4. Nodular soft tissue lesion on the peritoneal surface*

• A nodular soft tissue lesion is the most specific criteria for identifying peritoneal metastasis in patients with ovarian cancer. Note that CT performs similarly to MRI in identifying peritoneal disease, and both modalities perform well for implants greater than5 mm in size.
• The remaining options are not specific for peritoneal disease. Ascites and peritoneal thickening can be seen with peritoneal spread but can also be unrelated to malignancy (e.g. reactive).Small bowel wall thickening can be from a variety of causes.

Which of the following strategies can be used by radiologists when they are interpreting a study and the data are not fitting together?

1. Recommend another imaging study
2. Consult a colleague*
3. Leave exam for someone else to interpret
4. Follow-up case to determine if an error was made

• Consulting a colleague is a strategy that can be used by radiologists when they are interpreting a study and the data are not fitting together.
• The remaining options are not effective strategies to address when data are not fitting together.

Which of the following is a type of cognitive bias?

1. Edge of the film error
2. Alliterative error*
3. Communication error
4. Perceptual error

• Alliterative error is one of many cognitive biases and represents the influence that one radiologist’s judgment can exert on the diagnostic thinking of another radiologist.  An example is when a radiologist interprets a liver lesion on MRI as focal nodular hyperplasia (FNH) because the prior radiologist called it FNH, even though it has imaging features characteristic of hepatocellular carcinoma.
• Edge of the film error occurs when an important finding is missed because it is at the edge of a study, such as in the periphery of an x-ray or on the top or bottom images of aCT of the abdomen and pelvis. This is a form of blind spot error.
• Communication errors represent a type of error related to communication of important findings to other providers and are unrelated to cognitive biases. Examples include unclear and ambiguous reports, as well as instances in which important findings are not communicated directly to ordering providers with documentation in the radiology report that communication occurred.
• Perceptual errors are a general category of errors in which an important finding is missed by a radiologist, but visible in retrospect. Perceptual errors can happen for many reasons, including systematic factors like fatigue and cognitive biases such as satisfaction of search.

Framing bias:

1. Reflects the undue influence that an initial interpretation has on the evaluation of subsequently collected information
2. Results from a tendency to be influenced by how a question is asked or how a problem is presented*
3. Refers to the tendency for diagnostic assessments to be unduly influenced by easily recalled experiences
4. Represents the influence that one radiologist’s judgment can exert on the diagnostic thinking of another radiologist

• Framing bias results from a tendency to be influenced by how a question is asked or how a problem is presented
• Anchoring bias reflects the undue influence that an initial interpretation has on the evaluation of subsequently collected information
• Availability bias refers to the tendency for diagnostic assessments to be unduly influenced by easily recalled experiences
• Alliterative bias represents the influence that one radiologist’s judgment can exert on the diagnostic thinking of another radiologist

Which of the following is a system-related cause of diagnostic error?

1. Hindsight bias
2. Alliterative error
3. Case complexity
4. Workload*

• System-related errors are the result of environmental factors such as workload, staffing, inefficient processes, communication errors, lack of teamwork, and interruptions.
• Hindsight bias is a cognitive bias that refers to the tendency to overestimate the predictability of an event after the event is known.
• Alliterative bias is a cognitive bias that represents the influence that one radiologist’s judgment can exert on the diagnostic thinking of another radiologist
• Case complexity may be associated with more frequent errors, but is not a system-related cause of errors.