Blood clots among most common resident misses in CT scans

Studies suggest on-call residents perform well in limiting errors between preliminary and final reports. But mistakes happen—and they occur more often in abdomen and pelvis CT scans compared to other parts of the body.

In a retrospective study published online Feb. 3 in Current Problems in Diagnostic Radiology, researchers from Duke University Hospital examined common errors radiology residents make when interpreting abdominopelvic (AP) CT while on call.

The group analyzed a total of 4,695 CT scans performed over 518 consecutive weekend call shifts in six month increments between January through June 2011. A total of 145 misses were found.

These discrepancies were evaluated for their impact on short-term management—specifically if they could influence decision-making between the preliminary and final report. If so, it was considered a significant miss.

Discrepancy results were as follows:

• Blood clots were the most commonly missed condition with 20 total, accounting for 13.8 percent of misses.
• 12 cases of missed colitis were found, amounting to 8.3 percent of all misses.
• There was a total of 10 misplaced devices, accounting for 6.9 percent of total misses.
• Pyelonephritis rounded out the last category of common misses with eight cases or 5.5 percent of total misses.

“Residents should be cognizant of the vasculature (in particular the pulmonary arteries), colon, devices and kidneys when interpreting AP CT. Increased scrutiny of these sites of common misses could help reduce discrepancy rates,” wrote corresponding author Benjamin Wildman-Tobriner, MD, with the department of radiology at Duke University Hospital.