Recently an interesting retrospective study evaluating missed neurological emergencies was published in the journal ‘Diagnosis’. Physicians from the emergency department of large tertiary care center reviewed cases involving a missed or delayed diagnosis of a neurologic emergency in which a diagnostic error in the ED management was identified. Out of 1168 cases reviewed, 42 were found to have a missed acute neurologic diagnosis, 29 of which were attributed to error. These 29 cases were individually reviewed by the three emergency physician investigators. Of these, approximately 24% were attributed to a radiology resident misread.
The diagnosis most commonly missed was posterior fossa strokes. At their institution, preliminary reports are issued overnight and clinical decisions and disposition of these patients are often made prior to the final read. The authors suggest that ED physicians should consider requiring real-time attending radiologist reads on all ED neuroimaging to reduce the rate of preliminary misreads. There appears to be a growing trend among academic centers to increase resident supervision by attending physicians overnight in order to reduce the number of misreads by inexperienced radiology residents, though this is not the standard of care in the US. From a patient safety perspective, this data certainly supports that notion. At the institution where I am training, there is ED coverage by an attending physician approximately 21-22 hours/day.
Interestingly, they found no difference in error rates between the first and second halves of the academic year. This is incongruent with other studies that have demonstrated an increased amount of medical errors in teaching hospitals when new interns begin, commonly known as the “July Effect”. Radiology residents, however, are not allowed to take call independently until after 6 months of training, which could in theory result in a “January Effect”. It would be interesting to know if there was a correlation with timing in the academic year to specifically misreads in the radiology preliminary report.
Another point this study emphasizes is the importance of the clinician understanding the limitations of neuroimaging, especially in the initial hours following onset of symptoms, such as in the setting of an acute stroke, when head CT may often be normal. Radiologists could play an important role in reducing this type of error by more actively educating emergency department physicians of the appropriate role of neuroimaging in the ED setting and common pitfalls/limitations.
What are your thoughts on providing 24 hour radiology attending coverage for the emergency department? Do you believe that offering educational opportunities to emergency department physicians would help improve outcomes?
