Systemic Error in Radiology

AJR Am J Roentgenol. 2017 Sep;209(3):629-639. doi: 10.2214/AJR.16.17719. Epub 2017 Jul 25.


Objective: Interpretive errors in diagnostic imaging result in significant patient morbidity and mortality, but the importance of errors and process failures in the imaging cycle other than during image interpretation is underappreciated. In this article, we describe these errors and potential solutions, providing a framework to improve patient safety and understand the changing roles of radiologists beyond image interpretation.

Conclusion: For comprehensive improvements to health care delivery, other failures in the cycle besides diagnostic interpretive error-such as ordering inappropriate studies, PACS failures, and a lack of accurate clinician contact information (with resultant communication failure)-should be recognized as contributors to patient harm because they lead to wasted resources and delayed care. By taking ownership of the entire imaging cycle, radiologists can increase their net worth to patient care and cement their roles as experts in the effective, evidence-based use of imaging technologies.

Keywords: appropriateness criteria; error in radiology; imaging cycle; systemic error.

MeSH terms

  • Checklist
  • Decision Support Systems, Clinical
  • Diagnostic Errors / prevention & control*
  • Guideline Adherence
  • Humans
  • Medical Order Entry Systems
  • National Academies of Science, Engineering, and Medicine, U.S., Health and Medicine Division
  • Patient Safety
  • Practice Guidelines as Topic*
  • Radiography / standards*
  • Safety Management / methods*
  • United States