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04/16/2013

Reducing medical errors, one photograph at a time?

Xray
A doctor examines an X-ray photograph of a swine flu patient in March. (AFP PHOTO / Sam Panthaky)

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

Comments

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An MD is not an orthopedic specialist
So when an RMT and a RPT read a MRI and say the disc damage is herniation at L5-S1 and the report is sent back for a second reading . why would it be sent to the same radiologist? and they tel the MD what it is.
Client is in physical therapy for a herniated disc according to a differential observational signs and symptoms. not according to her MD

An ill-conceived idea. Adding a photo to the x-ray, is adding another potential source of error. The frequency of of adding an incorrect photo is likely to be similar to the frequency of mislabeling the x-ray in the first place. So, no gain in safety yet a big gain in workload.

In any case, as a practising doc, I can tell you that I, and most of my colleagues, wouldn't know our patients' faces well enough to detect an error if it occurred. It's one thing to know your patients' faces in the office setting, and quite another in the hectic environment of a medical ward or ER where you've only met the patient once (or not at all, i.e x-ray is reviewed before the patient is reviewed).

I am sure Canadian Medical Protective Association would make sure no lawsuit for malpractice in these cases ever succeeds, no matter how deserving.

How many of these reports are re-written as a way to conceal damage caused by hospital negligence..I have 4 radiology reports that were changed and it was not to add additional findings. These are made to look like original reports and the original reports are missing..Two other reports I suspect are not legit at all..For example a bone scan I had done claims my spine had nothing wrong contradicting the MRI and x-ray that shows 10 findings in total.And a comment made on the bone scan claiming no damage in the cervical spine but the MRI shows that is were the maximum amount of damage is also seen in the x-ray the bone is ossified..Be cautious in trusting these reports as being truthful if negligence and falsified records was involved and especially if the tests are being reviewed at the same hospital where the negligence occurred..Leaving the country to get tests may be the best idea.

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