Ivan Catalin Vasile, Mullineux Joseph H, Shah Vikas, Verma Ratan, Rajesh Arumugam, Stephenson James A
1 Department of Radiology, Gastrointestinal Imaging Group, University Hospitals of Leicester, Leicester General Hospital , Leicester , UK.
Br J Radiol. 2018 Nov;91(1091):20180142. doi: 10.1259/bjr.20180142. Epub 2018 Jun 27.
Radiology misses have been the subject of much debate on both sides of the Atlantic in recent years. There is now greater focus in trying to reduce radiology errors by continuous education and changing the working environment to try and protect the radiologist, and ultimately the patient from potential harm. Duty of candour is a relevant and sensitive area. Developing robust validated reporting pathways within the healthcare structure is very important so as to encourage a "learning from discrepancies" culture and to put the patient and their families at the center of reporting and acknowledging errors in radiology. Having reflected in our daily practice and while writing this pictorial review, we have concluded that during reporting MRI scans, routine assessment of the localizer images, focusing outside the area of interest and having a more structured approach to image interrogation are key actions which may help reduce the number of omissions. We present a myriad of cases where pathology was "missed" outside the center of gaze in relation to the abdomen or outside the abdomen on abdominal MRI, and suggest key high yield sequence related review areas to minimize the chance of missing potentially significant pathology.
近年来，放射学漏诊在大西洋两岸一直是备受争议的话题。现在人们更加关注通过持续教育以及改变工作环境来减少放射学错误，试图保护放射科医生，并最终使患者免受潜在伤害。坦诚义务是一个相关且敏感的领域。在医疗保健结构内建立健全且经过验证的报告途径非常重要，以便鼓励一种“从差异中学习”的文化，并将患者及其家属置于放射学报告和承认错误的中心位置。在我们的日常实践以及撰写本图文综述的过程中，我们得出结论，在报告磁共振成像（MRI）扫描时，对定位图像进行常规评估、关注感兴趣区域之外的部位以及采用更结构化的图像解读方法是关键行动，可能有助于减少漏诊数量。我们展示了大量病例，这些病例中腹部MRI检查时，病理情况在注视中心之外的腹部区域或腹部以外被“漏诊”，并提出关键的高收益序列相关复查区域，以尽量减少遗漏潜在重大病理情况的可能性。
