The legal implications of error in radiology

Evaluation of a deep learning-based computer-aided detection algorithm on chest radiographs: Case-control study

Along with recent developments in deep learning techniques, computer-aided diagnosis (CAD) has been growing rapidly in the medical imaging field. In this work, we evaluate the deep learning-based CAD algorithm (DCAD) for detecting and localizing 3 major thoracic abnormalities visible on chest radiographs (CR) and to compare the performance of physicians with and without the assistance of the algorithm. A subset of 244 subjects (60% abnormal CRs) was evaluated. Abnormal findings included mass/nodules (55%), consolidation (21%), and pneumothorax (24%). Observer performance tests were conducted to assess whether the performance of physicians could be enhanced with the algorithm. The area under the receiver operating characteristic (ROC) curve (AUC) and the area under the jackknife alternative free-response ROC (JAFROC) were measured to evaluate the performance of the algorithm and physicians in image classification and lesion detection, respectively. The AUCs for nodule/mass, consolidation, and pneumothorax were 0.9883, 1.000, and 0.9997, respectively. For the image classification, the overall AUC of the pooled physicians was 0.8679 without DCAD and 0.9112 with DCAD. Regarding lesion detection, the pooled observers exhibited a weighted JAFROC figure of merit (FOM) of 0.8426 without DCAD and 0.9112 with DCAD. DCAD for CRs could enhance physicians' performance in the detection of 3 major thoracic abnormalities.

Medicolegal training in radiology; an overlooked component of the non-interpretive skills curriculum

OBJECTIVE

Radiologists comprise approximately 3.6% of US physicians while ranked 6th-8th in medicolegal claims. Studies suggest that by the age of 60, about half of all radiologists will be sued at least once. Given this likelihood, it is surprising how little attention is paid to teaching of medicolegal issues. It is hypothesized that most trainees emerge from residency with only a vague notion of the medicolegal issues inherent in radiology.

METHODS

All of the radiology attendings, trainees and alumni in our tertiary care teaching hospital were surveyed via an electronic questionnaire. Respondents were surveyed on overall knowledge of job-related medicolegal issues and willingness to receive additional education. The survey also included two real life medicolegal scenarios and the radiologists were asked to choose the most likely outcome.

RESULTS

A questionnaire was sent to total of 359 trainees, attendings and alumni. There were 168 responses, constituting a 46.7% response rate, F:M 48:112. Only 41% of the respondents were aware that by the age of 60, half of them would be involved in at least one lawsuit. All knew the most common causes of malpractice claims; however, one-fourth were not aware of available medicolegal resources offered by radiological organizations; 85% of the respondents expressed willingness to attend medicolegal CME courses. All residents surveyed believed that medicolegal lectures should be included in their didactics.

CONCLUSION

There is a dearth of knowledge among radiologists on job-related medicolegal topics. This survey suggests that incorporating additional medicolegal topics into the non-interpretive skills curriculum of residents and medicolegal CME for graduates would be well received.

Overdiagnosis and overimaging: an ethical issue for radiological protection

AIMS AND OBJECTIVES

This study aimed to analyse the key factors that influence the overimaging using X-ray such as self-referral, defensive medicine and duplicate imaging studies and to emphasize the ethical problem that derives from it.

MATERIALS AND METHODS

In this study, we focused on the more frequent sources of overdiagnosis such as the total-body CT, proposed in the form of screening in both public and private sector, the choice of the most sensitive test for each pathology such as pulmonary embolism, ultrasound investigations mostly of the thyroid and of the prostate and MR examinations, especially of the musculoskeletal system.

RESULTS

The direct follow of overdiagnosis and overimaging is the increase in the risk of contrast media infusion, radiant damage, and costs in the worldwide healthcare system. The theme of the costs of overdiagnosis is strongly related to inappropriate or poorly appropriate imaging examination.

CONCLUSIONS

We underline the ethical imperatives of trust and right conduct, because the major ethical problems in radiology emerge in the justification of medical exposures of patients in the practice. A close cooperation and collaboration across all the physicians responsible for patient care in requiring imaging examination is also important, balancing possible ionizing radiation disadvantages and patient benefits in terms of care.

Use of contrast media in diagnostic imaging: medico-legal considerations

Contrast media (CM) are used in imaging techniques to enhance the differences between body tissues on images. The ideal contrast medium should achieve very high concentration in the tissues without producing any adverse effects. Unfortunately, this has not been possible so far and all CM have adverse effects. The increasing use of CM is likely to give rise to a wide range of pitfalls, including compliance with and appropriateness of indications for the use of CM themselves, the choice of the ‘best’ contrast agent, off-label use, evaluation of special populations of patients, and competence to tackle emergency scenarios following the administration of CM. Even more prominent, and potentially more important, is the issue of informed consent which brings with it a duty to inform patients awaiting the administration of CM with regard to the nature of the procedure, the existence of alternative procedures, the extent of the risks relating to the use of CM and, finally, the risks relating to refusal of the procedure. All these issues may give rise to concerns about liability for failure to offer adequate information to patients or to carefully evaluate and balance the potential risks and benefits of the procedure or, finally, for being unprepared in the event of adverse reactions to CM, especially when these are severe and life-threatening. Educational and training programmes for radiologists are likely to shape change in the medical liability environment in the coming years.

Errors and malpractice in interventional radiology

Interventional radiology is an invasive specialty with the potential for errors as with other invasive specialties. A critical analysis of the different types of errors may help radiologist undertake the corrective measures. Standardize interventional procedures with protocols applicable to clinical practice are necessary to avoid the malpractice and, therefore, the related medical-legal issues. In this article, we present an overview of principal differences between errors and malpractice with particular regard to the issues in interventional radiology. Specific topics discussed in this article are the approaches to preventing errors and, thus, to avoiding the malpractice in interventional radiology.

Spectrum of diagnostic errors in radiology

Diagnostic errors are important in all branches of medicine because they are an indication of poor patient care. Since the early 1970s, physicians have been subjected to an increasing number of medical malpractice claims. Radiology is one of the specialties most liable to claims of medical negligence. Most often, a plaintiff's complaint against a radiologist will focus on a failure to diagnose. The etiology of radiological error is multi-factorial. Errors fall into recurrent patterns. Errors arise from poor technique, failures of perception, lack of knowledge and misjudgments. The work of diagnostic radiology consists of the complete detection of all abnormalities in an imaging examination and their accurate diagnosis. Every radiologist should understand the sources of error in diagnostic radiology as well as the elements of negligence that form the basis of malpractice litigation. Error traps need to be uncovered and highlighted, in order to prevent repetition of the same mistakes. This article focuses on the spectrum of diagnostic errors in radiology, including a classification of the errors, and stresses the malpractice issues in mammography, chest radiology and obstetric sonography. Missed fractures in emergency and communication issues between radiologists and physicians are also discussed.

Clinical Risk Management in radiology. Part I: general background and types of error and their prevention

The present contribution, presented as an Editorial, addresses the issue of patient safety in Radiology: this topic, of great current National and Regional interest, has stimulated a strong focus on accidents and mistakes in medicine, together with the diffusion of procedures for Risk Management in all health facilities. The possible sources of incidents in the radiological process are exposed, due to human errors and to system errors connected both to the organization and to the dissemination of Information Technology in the Radiological world. It also describes the most common methods and tools for risk analysis in health systems, together with some application examples presented in Part II.

Medical malpractice: the experience in Italy

At the present time, legal actions against physicians in Italy number about 15,000 per year, and hospitals spend over 10 billion euros (approximately US$15.5 billion) to compensate patients injured from therapeutic and diagnostic errors. In a survey summary issued by the Italian Court for the Rights of the Patient, between 1996 and 2000 orthopaedic surgery was the highest-ranked specialty for the number of complaints alleging medical malpractice. Today among European countries, Italy has the highest number of physicians subject to criminal proceedings related to medical malpractice, a fact that is profoundly changing physicians' approach to medical practice. The national health system has paid increasingly higher insurance premiums and is having difficulty finding insurance companies willing to bear the risk of monetary claims alleging medical malpractice. Healthcare costs will likely worsen as Italian physicians increasingly practice defensive medicine, thereby overutilizing resources with the goal of documenting diligence, prudence, and skill as defenses against potential litigation, rather than aimed at any patient benefit. To reduce the practice of defensive medicine and healthcare costs, a possible solution could be the introduction of an extrajudicial litigation resolution, as in other civil law countries, and a reform of the Italian judicial system on matters of medical malpractice litigation.