Radiology Malpractice Claims Review Drives Suggestions for Improvement

December 21, 2018 — Editor's note: This article has been updated for clarity.

Among medical specialists most likely to be named a defendant in a medical malpractice claim, radiologists rank sixth, as cited by a recent data review of closed court claims.

The report — issued by the Cooperative of American Physicians (CAP), a member organization that provides professional liability coverage to nearly 12,000 doctors in California — recommends improvements in diagnosis, communication, performance measurement, ways to avoid misinterpretation, and ways to get more information prior to imaging.

Of 68 claims that resulted in an indemnity payment between 2006 and 2015 and were reviewed in the report, 83% were related to diagnostic error and 17% were related to a procedural, technical competence, equipment, or communication error.

We were surprised when we saw diagnostic error being so much higher than the average in radiology.

"We were surprised when we saw diagnostic error being so much higher than the average in radiology. The national average is 54% for missed diagnosis," Ann Whitehead, RN, JD, vice president of risk management at CAP, told Medscape Medical News in an interview.

The "83% diagnostic error rate" in radiology is "significantly higher" than the rate seen in other specialties, she reported.

The report was discussed during the recent Radiological Society of North America (RSNA) 2018 Annual Meeting in Chicago.

However, those recommendations and other findings from the review are not based on robust data, said Leonard Berlin, MD, from Skokie Hospital in Illinois, who is the author of Malpractice Issues in Radiology, a book now in its third edition.

"I don't see any merit in this publication at all," Berlin told Medscape Medical News.

Both the American College of Radiology and the RSNA, which represents 54,000 members, recommended getting in touch with Berlin for a response to the report.

Although communication failures happen "more often than they ought to," Berlin acknowledged, the authors "are making a judgment based on 68 cases, when there are about 45,000 radiologists in the United States."

One section of the report (page 2, paragraph 2) states that multiple factors leading to diagnostic errors are "not surprising, as multiple factors would logically impact quality and accuracy of an interpretive diagnosis, including the ordering physician requesting the wrong study, reliance on poor quality images, and the radiologist's technical or judgment errors."

There is no basis for any of those statements.

"There is no basis for any of those statements. That's nonsense!" Berlin said.

Whitehead reported that 60% to 65% of claims against any physician result from incidents that occur in a hospital.

"A lot of them are in surgery, or obstetrics, or primary care. From my perspective, I would not have thought that radiology would be ranked so high," she told Medscape Medical News. "You'd think after all these years we would be better at mammography, diagnosis, but error is still occurring."

Communication is often at the root of diagnostic errors. Radiologists "have a limited amount of info prior to test reading. They don't have access to other films. We hope to reinforce the idea that they need better communication and better access to previous digital x-rays and background information," she explained.

"From the cases we have in our study, we think a lot of errors could have been prevented if the radiologist had more info," she added.

Case Studies Cited

In one case, which resulted in a $500,000 settlement, a dislocated shoulder was missed because a chest x-ray was ordered for a "cough." In another, which resulted in a $30 million settlement, the patient was finally diagnosed with locked-in syndrome after a stroke, but the MRI that had been ordered was read by the radiologist but was considered limited "due to motion artifact."

"I would love to see the actual facts" of the locked-in syndrome case, Berlin said. It "doesn't sound right. Usually that kind of stuff gets a lot of publicity. Seems fishy or incomplete."

"They say the radiologist had a lack of information," he added. "How can a radiologist do something without information? This is hardly ever an issue."

He was equally skeptical of the dislocated shoulder case. "Chest x-ray with one view? We always do two views. Nonsense! That doesn't happen. A patient went 4 months with a dislocated shoulder? I don't understand that at all. Four months? With a bilateral dislocated shoulder?"

He went on to say that calling out "interpretation areas and communication issues" as a problem is not "earth-shattering" information. "That's what we do for a living. We need to address diagnostic challenges. I don't know what they're talking about."

"We're never going to do away with errors," but there's always room for improvement, Berlin pointed out.

The error rate in medicine issued by the Mayo Clinic ranges from 10% to 15% overall, and for radiology is about 2.9% (Insights Imaging. 2017;8:171-182). "This is a well-known error rate that everyone knows in radiology," he said.

Among the diagnosis-related cases cited in the CAP report, 25% involved cancer, 11% involved alleged missed or delayed diagnosis of breast cancer, 12% involved alleged missed or delayed diagnosis of lung cancer, and 7% involved alleged missed fracture.

Harm or Good?

"I'm not actually disturbed by this. The CAP is a physician-run and organized malpractice insurance company," said Stephen Latham, JD, PhD, from the Yale Interdisciplinary Center for Bioethics in New Haven, Connecticut.

"This publication is aimed not at the public but at their insured docs. It is supposed to help practicing radiologists learn how to avoid getting sued. That's good for the radiologists and, of course, good for the insurance company," he told Medscape Medical News.

He said he would be surprised if the stories and data were inaccurate because the whole point of the report is to help the people the organization insures avoid lawsuits by putting various preventive programs in place and learning what kinds of action trigger malpractice suits.

"The CAP website is full of similar articles for other practice areas — basically lessons for docs on how to structure their practices to avoid the mistakes that lead to lawsuit," he added.

But Berlin said he worries that this report will lead to false perceptions. Most errors made don't really injure the patient, and malpractice cases are quite rare and need a really strong foundation. A radiologist is more likely to get hit by a car on the way to work than to get sued, he noted, but "every now and then something goes wrong and someone is going to sue."

"I'm disappointed," Berlin said. "I feel this report adds nothing of value for the public or to our professionals."

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