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Errors in Radiology:

artifacts, medical malpractice


or just a simple misunderstanding?

Elżbieta Anna Leśniewska


DNI AKX225479
To begin with it is important to understand what the radiology is. As we all know
radiology is a medical speciality, which uses imaging to diagnose and treat diseases, but
from more practical point of view medical imaging is nothing more or less then just a
powerful weapon of every doctor in the big fight in which he may win the health of his
patient. Not every of those fights is easy. Mostly because every radiological picture
visualizing the disease brings us a huge risk of making a mistake.
ERRORS- WHERE AND WHY DO THEY OCCUR?

There are several levels of mistakes in medical imaging. The first group is considering errors
connected with the way the photo has been taken, the equipment and facilities that have been
used or the hospital's personnel being unfocused. Those mistakes are called classic technical
errors. Here we can find malpositioning, patient motion, incorrect patient identification,
incorrect examination and double exposure. Some of them could sound ridiculous and seem
unbelievable, but according the statistics they still occur with quite high frequency.
In the statistics published in United States on the pages of Washington Post the most common
reason of mistakes is improper use of drugs such as dyes, sedatives and blood thinners. There
have been described cases of failing to give a drug to the patient, administrating it incorrectly or
in a wrong dose, sometimes there were the names of drugs confused.
WHAT ARE THE ARTIFACTS?

Etymology of the word 'artifact' points that it comes from two latin words- 'ars', skill and
'facere', to make. When we try to connect those words with the radiological imaging we
are able to find the meaning of the artifact as 'any product, structure or appearance that is
not natural, which can appear on a scan as a distortion or fuzziness, caused by
manipulation (for example during compression of a digital file).' There are three points
of imaging that could caused a failure of an image depending on the causative agent.
The first one is a hardware source of artifact, where as examples could serves the
calibration and power stability. Then we have software source (programming errors) and
the third one is an operator's artefact.
For an instance we could also classify artifacts by the mechanism of interference with
image acquisition, processing, display. Nowadays, in the boom of development, new
technologies and experiments, scientists are building and creating different systems to
improve the imaging process. Radiologists could use programs to the computer
radiography (CR), which is a system using photostimulable luminescence, direct digital
radiography (DDR) that make digital radiography from the photoelectric interaction of
X-rays with the detector itself, indirect digital radiography (IDR) sensitive to the light
produced by an intensification screen, optically coupled direct radiography (OCDR)
which use optics components to focus fluorescence onto charge coupled detectors
(CCD). People working on the improving systems and physicians have decided that
there are some requirements that have to be met if there is a will to produce a good
radiographic image. The most important goals for radiological specialists are terms like:
tube potential, beam current, source-to-image distance, collimation, alignment of the X-
ray central ray, positioning of detector and subject for the specific anatomic projection.
What is more the detector must receive enough X-rays to make a good image. If so
many things are needed to be obtained, there is no surprise that not every visualization is
perfect and artifacts are often masking a clinical feature.
Common artifacts that doctors could
find in their practice:
– Underexposed radiography
or overexposed one
(loss of contrast)
– Improper calibration
(loss of contrast in dense
features, fig no4)
– Chemical Shift Artifact which takes it's reason in the wrong frequency direction.
The difference between the resonant frequency of two tissues (most common in
vertebral bodies, orbits and solid organs surrounded by fat) produce high
intensity and low intensity bands near fat/water interfaces. Those dark
boundaries on an image are often called "contour artifacts"

– Corduroy artifact, also known as Spike Noise or White Pixels. "Corduroy" refers
to the parallel line patterns that are frequently seen in the produced image. Those
lines are caused by pronounced or bright areas and typically created by arcs
received by the system. It appears very different from image to image and it's
considered as a digital problem.

– Wraparound- the field of


view is not big enough to
picture the whole part of a
body so it's parts extends
beyond one edge of image
and it is projected on the
opposite side.
– Black line artifact-
is a black line located at fat/water
interfaces

– Gibbs or truncation artifacts are bright


or dark lines that are seen parallel and next
to the borders of abrupt intensity change.
Those lines may simulate a syrinx on
sagittal image of spinal cord. The artifact is
related to the finite number of encoding steps.

– Zipper artifacts, also called stars or 'zero line


artifact' and are related to hardware or
software problems beyond the radiologist
control. It is often caused by a large noise
signal, which because of the huge amplitude
could shows up as a dashed pattern in the
reconstructed image.
– Metallic artifacts are caused by changes in the magnetic field inducted by some
magnetic metals being able to dramatically distort that static field. This artifact is
very common because of the great number of objects that a patient wears or has
on himself. Here we can find ferromagnetic or non-ferromagnetic metal, dental
amalgams, implants or even cosmetics with some dose of iron or cobalt. This is
the reason why every patient is always asked to take off all the metallic stuff
while he is been preparing to the
radiography.

– Central Point Artifact is a focal dot


increased or decreased signal in the centre
of an image. Radiologists could correct
them recalibrating the machine and
maintaining a constant temperature in
equipment room for amplifiers.

– Ghost is the name of distortion where


appears another image rotated 180 degree.
It shows two combined signals
of different intensity causing unbalanced
gain in the two channels. To minimize
the effect specialists usually change the
calibration scans or use image filtering

– Errors in data happen where the are some


failures of the array processor producing
a variety of strips and pattern on reconstructed images. Errors in data can cause
striped images, wash out images and the zipper artifacts.

– Surface coil artifact is an artifact connected with the sensitivity of surface coils
that falls off dramatically with distance from the coil. The reason has been found
in the higher intensity of tissues closed to the surface coil then the intensity of
the tissues laying much farther.
WHEN A MISTAKE BECOMES A MALPRACTICE

Every radiologist and a doctor who is checking the results of the further examinations of
his patients almost every day is dealing with the interpretation of diagnostic films like
CT scans, MRI, X-rays, ultrasounds, sonograms. That everyday routine could
unfortunately cause some errors, which are very common form of a medical malpractice.
In recent years the newspapers, television and other kinds of mass-media are screaming
loudly about new victims of misreads and misinterpretations. Obviously some of those
mistakes, even those which from the wider point of view could seem just a trifle to us,
are fatal and without any doubts it is clear that medical personnel must be aware to all
the consequences of his diagnosis.
Acorrding to the statistics over 12% of the 2,000 radiology errors last years resulted in
some degree of harm to the patient. What is more analysis shows that that percent is
seven times more severe then medication errors.
Radiology errors can result not only from the radiologist misinterpreting a scan but from
a lack of communication between the radiologist and the other treating physicians.
Becoming a doctor everybody needs to remember that he is responsible for the patient's
health and he needs to do all what is the best for the patient. It is important to remember
that every patient is protected by the law and he can always vindicate his right in a court.

Case number 1
15 years-old boy showed up in a hospital because of the acute headache
and a loss of the consciousness. After brain CT which showed an
aneurysm doctors decided to transport him to the neurosurgery ward in
another specialistic health centre to do indispensable surgery as soon as it
possible. Everything was going well until the operation has started and the
surgeons realized that the aneurysm was not there. After the surgery the
scan has been aisled once again and then the radiologist admitted that he
had made a mistake in a scan description. The boy died during the after
surgery recovery.
Case number 2
50 years-old man presented for a chest X-ray as a part of pre-employment
physical exam. The result was interpreted as normal except for a dense
area in his right upper lobe, which was diagnosed as an artifact. Few
months later the patient came back to the doctor complaining of the chest
pain, disnea, loss of weight and dry exhausting cough. The chest X-ray has
been repeated and it showed a large tumour in the same area as his
previous scan. In other words the thing which was diagnosed as an
artifact turned out to be a cancer. The patient died six month later because
of the tumour growth and metastasis. Undoubtedly if he was diagnosed
correctly earlier he would have more chances to stay alive.

Case number 3
28 years-old pregnant woman who came to the emergency room with a
vaginal bleeding. She was immediately sent for an ultrasound to assess
her baby's health. The test showed no fetal movement. Unfortunately
instead of sending the woman to the surgeon to do a caesarean section the
radiologist only wrote the test's result in the chart. Because of the delay in
her obstetrician getting the results her baby was not delivered for another
hour. The baby survived, but was left with permanent brain damage.
AVOIDING MISTAKES

However the level of errors in the radiology could be surprising and terrifying, being
wrong is still a human thing. Suspending every doctor who makes an error today will
not change the reality to a better one. What we could do then? First of all every doctor
who is ready to ´read´ a scan must be well informed and wisdom about what kind of
mistake can occur on the photo he is holding in his hand. Misinterpretations of
recognized findings may due to a number of factors such as bad communication between
the workers in the same hospital, careless done research on a patient's chart, incorrect
clinical information. Naturally most of those factors could be prevented by improving
knowledge and skills, being aware of history and clinical symptoms and right selection
of the imaging methods or clinical investigation in the first place.
On the both patient's and doctor's side is the technique. During many years of the
development of the radiological imaging scientists have found plenty of ways to
improve their skills and to managed new systems and machines which are nowadays
useful in radiology. The progress includes changes in the working conditions, equipment
alteration to prevent accidental error, double reporting, regular, recorded dialogue
between clinicians and radiologists and data bases on the web sites connecting each one
hospital taking a part in a programme.

CONCLUSION

The painful but truly thing is that an error is inevitable and it is write down into the life's
cards of every doctor in the world. Another truth everyone could shares is a good
medicine's will of making progress and a will of every doctor to become much better
every day. There are no doubts that errors in radiology happens. There could be called
an artifact, malinterpretation, malpractice or be caused by an accident or
misunderstanding between two people. After all we need to remember that as well as
radiology medical studies are still on their way to perfection, which leads the
radiological examination to the highest level of imaging and also the better interpretation
and diagnostic.