Malpractice claims plague radiologists, deplete resources

Compelling new data from the U.K. reveal that the most common causes of negligence claims against radiologists are missed fractures, malignancies of the breast, lung, and sigmoid, developmental abnormalities, and subarachnoid hemorrhages.

Greater awareness of high-risk investigations is useful for day-to-day practice and may contribute to the development of more robust investigational algorithms for these procedures, according to a poster presented at the 2004 RSNA meeting.

Complaints and litigation against healthcare professionals can compromise individual careers, affect clinical practice, and deplete healthcare resources, noted lead author Dr. Peter Cowley, department of radiology, Royal Free Hospital, London. In the U.K., radiology accounts for a relatively modest share of negligence claims, but the growing sophistication of imaging techniques and practitioners' increasing reliance on them may cause this to change.

"It is very much in the interests of patients, the profession, and healthcare workers as a whole that we learn from our mistakes to improve clinical practice and reduce risk," the poster stated. "Errors of perception leading to missed diagnoses are inevitable. 'Everyone makes mistakes' is a cliche, but undoubtedly true."

The authors examined all serious complaints made wholly or partly against radiologists in the National Health Service between 1 April 1995 and 31 March 2004. Data were obtained from the NHS Litigation Authority, which was set up in 1995 to oversee a central fund dealing with medical negligence and litigation in England.

The researchers found a total of 484 complaints of negligence involving radiology departments in England. About 2% of these resulted in court action, while the remainder were withdrawn or settled out of court. In 91 cases (19%), the claimant received no settlement. Of the 10 largest claims, eight remain open, and only two have been settled.

Total settlements during this period exceeded British Sterling 57 million ( Euro 82 million), or by subspecialty (in millions): musculoskeletal British Sterling 6.6, breast British Sterling 3, chest British Sterling 1.9, gastrointestinal British Sterling 1.3, obstetric British Sterling 19.7, neurologic British Sterling 13.5, neurointerventional British Sterling 4.7, interventional British Sterling 2.3, urologic British Sterling 1.42, head and neck British Sterling 1.2, pediatric British Sterling 0.4, gynecologic British Sterling 0.5, deep vein thrombosis/Doppler British Sterling 0.4, and miscellaneous British Sterling 1.2.

Of the total complaints, 21.5% involved musculoskeletal examinations. 17.8% were breast, 9.9% chest, 9.7% gastrointestinal, 8.6% obstetric, 5.8% neurologic, 2.3% neurointerventional, 4.9% interventional, 2.2% urologic, 1.8% head and neck, 1.8% pediatric, 1.6% gynecologic, 0.4% deep vein thrombosis/Doppler, and 11.7% miscellaneous examinations.

"Most musculoskeletal complaints are for missed fractures by accident and emergency staff. A radiologist may have only been involved belatedly or not at all," the authors wrote.

Missed fractures, most commonly of the hands and feet, accounted for 55% of musculoskeletal claims. Missed carcinomas on mammograms were responsible for 83% of breast claims, and failure to spot lung cancer accounted for 43% of chest cases. Missed colorectal cancers (particularly sigmoid tumors) on barium enema accounted for 21% of gastrointestinal claims, and failure to detect fetal abnormalities was the basis of almost all obstetric cases. Among neurologic claims, missed subarachnoid hemorrhages and spinal pathologies (mainly tumors) were each responsible for 14%.

Stroke accounted for 81% of neurointerventional claims, while missed renal carcinoma accounted for 64% of urologic cases. Slipped upper femoral epiphysis was the cause of 41% of pediatric cases, and hip developmental dysplasia accounted for 22% of the total. Missed ovarian cancers resulted in 38% of gynecologic claims.

Nearly 71% of complaints related to missed diagnoses, and another 14% to injuries resulting from a procedure. About 5% of cases were due to delayed diagnoses, while 3% of the total resulted from miscommunication, 2% from false-positive diagnoses, 1.9% from a slip or fall, 1% from a reaction to contrast agents, 1% from clerical error, 0.8% from failing to report, and 0.6% from labeling errors.

Given the limited nature of the case descriptions, the missed diagnosis category may contain a substantial number of delayed diagnoses and failures to refer for further examinations. However, most of these cases resulted from perceptual errors subsequently deemed negligent, wrote the authors.

"Complaints of negligence are likely to plague radiologists for many years to come," they concluded.

According to an opinion piece in the British Medical Journal (2005;329: 1353), the current system for determining medical negligence in the U.K. is secretive, unaccountable, and unregulated. Expert witnesses are central to the system, but they are not subject to a regulatory code, audit, appraisal, and peer review. The quality of reports expert witnesses provide varies greatly, and many present inappropriate source material to support their opinions, wrote Dr. Michael Bishop, a consultant urologic surgeon at Nottingham City Hospital, U.K.

A new system based on a national register of coded incidents and their outcomes would promote consistency in the treatment of negligence claims and enable doctors to learn from errors. To restore faith, the profession must make itself transparent.