Here’s what radiologists should do after they’ve committed an error
Errors are a part of practicing medicine. And up to 4 million people in the U.S. will suffer a serious, misdiagnosis-related injury each year. But what should a radiologist do after they realize they’ve committed an error?
Frank J. Lexa, MD, MBA, chair of the American College of Radiology’s Commission on Leadership and Practice Development, recently posed this question to a handful of top rads after receiving a comment from a reader who chose to remain anonymous
Below are excerpts taken from the perspective, published Friday in the Journal of the American College of Radiology.
1) After a mistake, calling the referring physician to ensure the patient is taken care of is top priority, in addition to documenting discussions, according to Jennifer C. Broder, MD, vice chair of radiology quality and safety at Lahey Hospital & Medical Center in Burlington, Massachusetts.
The next move depends on the type of error. Disclosing the mistake to patients is a must, and rads should consider seeking guidance from experts, including risk managers, to discuss the problem and next steps.
2). While the “textbook” answer is to transparently report the miss, malpractice risks, financial and emotional costs should also be considered, said Richard L. Duszak, MD, vice chair for health policy and practice at Emory University’s Department of Radiology and Imaging Sciences.
The nuanced answer, he noted, is to “tread carefully” and do what’s necessary for the patient while mitigating your own risk. Most leaders have communication protocols and other risk-mitigation policies in place. If not, a phone call prior to any action may prove useful, Duszak added.
3). Radiologists should immediately notify ordering providers of any emergent findings, said Eric M. Rubin, MD, a radiologist with Crozer Health in Springfield, Pennsylvania. While perceptual misses make up most imaging errors, such mistakes are often spotted because the disease has already progressed.
Documenting the process and creating a report may protect rads should a civil suit arise, Rubin noted.
4). David Yousem, MD, MBA, director of neuroradiology at Johns Hopkins, has a four-step process: “Right it, own it, learn from it, share it.”
Radiologists should call the clinician after spotting a miss, correct the reports and put the patient first, Yousem noted Friday. Next up is to call risk management and outline all the facts of the situation.
Analyze why the oversight occurred and implement changes to try and prevent the next mistake, Yousem added. Finally, help others to avoid the same missteps as you.
Read the entire document here.
Matt joined Chicago’s TriMed team in 2018 covering all areas of health imaging after two years reporting on the hospital field. He holds a bachelor’s in English from UIC, and enjoys a good cup of coffee and an interesting documentary.