Error in radiology: classification and lessons in 182 cases presented at a problem case conference.

Abstract

The authors review and classify errors in 182 cases that were presented at problem case conferences between August 1986 and October 1990. Errors were classified by means of a system developed 20 years ago and by means of a system developed within the past several years. The authors found that sources of error have changed very little. Errors usually involved failure to consult old radiologic studies or reports, limitations in imaging technique, acquisition of inaccurate or incomplete clinical history, location of a lesion outside the area of interest on an image, lack of knowledge, failure to continue to search for abnormalities after the first abnormality was found, and failure to recognize a normal biologic variant. Errors included 126 perceptual errors (64 false-negative, 15 false-positive, and 47 misclassification errors) and 56 mishaps, including 38 complications and 18 communication errors. In seven cases nonperception errors occurred because established departmental routines were not followed, and in nine cases a new departmental routine was established after a complication occurred. Departmental policy exerts less effect on perception and interpretation errors.