Reducing medical errors, one photograph at a time?
Making too many medical mistakes involving mixed-up X-rays? Just put a face on it, a new study suggests.
The idea occurred to Dr. Srini Tridandapani one day when his cellphone rang and a picture of the caller popped up on the screen.
"I estimate that about one out of 10,000 examinations have wrong-patient errors," said radiologist Tridandapani, an assistant professor with Emory University School of Medicine, in a press release. "It occurred to me that we should be adding a photograph to every medical imaging study as a means to correct this problem."
Tridandapani decided to conduct an experiment where he paired patients' photographs with their X-rays. The study's sample size was tiny -- just 10 radiologists participated -- but Tridandapani found that errors were reduced five-fold when the pictures were used.
Tridandapani had the radiologists interpret 20 pairs of X-rays, both with and without photographs. Each set of pictures included between two and four mismatched pairs.
When photographs were included, the radiologists correctly identified the mistake 64 per cent of the time; without the photo, errors were only identified 13 per cent of the time.
Some radiologists didn't realize they could use the photographs for identifying mismatched X-ray images, however, and others flat out ignored the pictures because they thought they were there to distract them.
So Tridandapani repeated the experiment, this time explicitly asking the radiologists to use the photographs. "The error detection rate went up to 94 per cent in the second study," he says.
Obviously, this study is quite small and the idea will have to be further researched to see if the benefits offset the extra effort and money involved with photographing every patient who receives an X-ray.
And would physicians even remember the faces of their patients? This weekend, I attended a symposium on medical errors and learned of one particularly-dramatic case study that suggests perhaps not.
In this study, a 67-year-old woman, given the pseudonym Joan Morris, wound up receiving another patient's invasive heart surgery after hospital staff mixed her up with another patient -- a 77-year-old woman with a similar name.
Morris protested that she wasn't supposed to have the surgery but hospital staff insisted. They wound up paging the attending physician to come speak with her -- and even though the attending physician had already met the correct patient the day before, he failed to notice he was now speaking with a different woman.
Morris wound up in the operating room, where doctors essentially induced cardiac arrest on her for an hour before someone realized the mistake.
And here is the most astonishing part: Morris -- a high-school educated native English speaker whose daughter works as a doctor at that hospital -- wound up signing a consent form for the other patient's surgery.
This case study, if anything, highlights the fact that medical errors often come after a long chain of several smaller mistakes. And small simple solutions -- like, perhaps, adding a photograph to an X-ray -- are worth looking at if it means breaking that chain.
Jennifer Yang is the Star’s global health reporter. She previously worked as a general assignment reporter and won a NNA in 2011 for her explanatory piece on the Chilean mining disaster. Follow her on Twitter: @jyangstar