Identifying and Categorizing Diagnostic Errors in Abdominal Imaging Using a Diagnostic Imaging-Specific Annotation Process

Ronilda Lacson; Kristine S Burk; Jeffrey P Guenette; Pamela J DiPiro; Ariadne DeSimone; Nicole Vetrano; Ishani Ganguli; David W Bates; Ramin Khorasani

doi:10.1016/j.jacr.2026.06.006

Identifying and Categorizing Diagnostic Errors in Abdominal Imaging Using a Diagnostic Imaging-Specific Annotation Process

J Am Coll Radiol. 2026 Jun 9:S1546-1440(26)00296-6. doi: 10.1016/j.jacr.2026.06.006. Online ahead of print.

Authors

Ronilda Lacson¹, Kristine S Burk², Jeffrey P Guenette³, Pamela J DiPiro⁴, Ariadne DeSimone⁵, Nicole Vetrano⁶, Ishani Ganguli⁷, David W Bates⁸, Ramin Khorasani⁹

Affiliations

¹ Associate Director of Center for Evidence Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, Massachussetts; Associate Professor of Radiology, Harvard Medical School, Boston, Massachussetts. Electronic address: rlacson@bwh.harvard.edu.
² Medical Director of Safety, MGB Radiology, Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, Massachussetts; Assistant Professor of Radiology, Harvard Medical School, Boston, Massachussetts.
³ Medical Director of Quality for Neuroradiology, Mass General Brigham Radiology, Associate Director of Center for Evidence Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, Massachussetts; Associate Professor of Radiology, Harvard Medical School, Boston, Massachussetts.
⁴ Medical Director of Quality, MGB Radiology, Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, Massachussetts; Associate Professor of Radiology, Harvard Medical School, Boston, Massachussetts.
⁵ Medical Director of Quality for Thoracic Imaging, Mass General Brigham Radiology, Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, Massachussetts; Assistant Professor of Radiology, Harvard Medical School, Boston, Massachussetts.
⁶ Manager, Performance Management, Mass General Brigham Enterprise Radiology, Quality & Safety, Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, Massachussetts.
⁷ Associate Professor of Medicine, Harvard Medical School, Boston, Massachussetts; Department of Medicine, Brigham and Women's Hospital, Boston, Massachussetts.
⁸ Professor of Medicine, Harvard Medical School, Boston, Massachussetts; Medical Director of Clinical and Quality Analysis, Department of Medicine, Brigham and Women's Hospital, Boston, Massachussetts; Chair, Brigham and Women's Hospital Center for Patient Safety Research and Practice.
⁹ Director of Center for Evidence Based Imaging, Brigham and Women's Hospital, Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, Massachussetts; Radiology Vice-Chair of Quality and Assistant Chief Medical Officer; Professor of Radiology, Harvard Medical School, Boston, Massachussetts.

PMID: 42264062
DOI: 10.1016/j.jacr.2026.06.006

Abstract

Objective: This initiative aimed to identify and classify contributory factors to diagnostic errors in abdominal imaging using an annotation process to identify, quantify, and categorize process-related errors.

Methods: This was a retrospective, quality improvement, institutional review board-approved study conducted at an academic health system on 200 randomly selected adult patients who completed abdominal diagnostic imaging examinations between January 1, 2022, and December 31, 2022, in which a radiologist recommended additional imaging. We used an expert panel to develop a taxonomy based on two previously described taxonomies for process-related errors. We then applied an iterative process to train annotators to apply the taxonomy and assess medical records for diagnostic errors. We assessed the proportion of patients with diagnostic errors, as well as interrater reliability in classifying contributory factors. We also measured percentage agreement in identifying diagnostic errors using an annotation taxonomy versus a gold standard developed by two abdominal radiologists.

Results: The final sample included 185 patients. A total of 14.6% (27 of 185; 95% confidence interval 10.2%-20.4%) patients undergoing abdominal imaging experienced at least one diagnostic error. Interannotator agreement with the gold standard increased from 61.1% (33 of 54) at baseline for 5 reviewers to 80% (40 of 50) (χ²P = .04) after four rounds of annotation. "Delay in performing ordered test(s)" is the major contributory factor to diagnostic errors.

Discussion: Process-related diagnostic errors occurred in almost one in seven patients undergoing abdominal imaging with recommended additional imaging. After iterative training, an annotation process for identifying patients who have imaging diagnostic errors achieved significant interannotator agreement compared with a gold standard of radiology specialist review.

Keywords: Diagnostic errors; annotation process; diagnostic workflow.