For Residents, Missed-Case Conferences Mean Fewer Missed Cases

Everyone makes mistakes, but learning from them can nip future errors in the bud.

It turns out that conventional wisdom applies to medical imaging errors, too, Jason Itri, MD, PhD and colleagues reported in the October edition of the American Journal of Roentgenology.

Itri and his University of Pennsylvania team found that residents who attend conferences that focus on missed or misinterpreted cases are 67 percent less likely to miss important findings when reading on-call musculoskeletal X-ray images.

Itri and colleagues reviewed major discrepancies in musculoskeletal X-ray studies interpreted by radiology residents and fellows on call from July 2008 to July 2009. They found 31 common and important musculoskeletal injuries were missed or misinterpreted. These missed cases were presented during focused missed-case conferences for residents from July through October 2009.

The residents’ overall major discrepancy rate for all musculoskeletal X-ray studies was 1.19 percent before the missed-case conferences and 0.87 percent after them.

Residents had 55 major discrepancies out of 5,326 X-ray studies of the shoulder, elbow, hand, wrist, ankle, foot, pelvis, and knee before the launch of regular missed case conferences, Itri said. That number dropped to 18 major discrepancies out of 5,272 X-rays studies after the focus missed-case conferences became part of the resident education program.

Major discrepancy rates for residents who attended the conferences were lower than that for board certified fellows who did not attend the conferences, Itri said.

“During the time of the study, fellows had an overall major discrepancy rate of 1.5 percent diagnosing musculoskeletal injuries related to topics discussed during the missed-case conferences, while the residents’ overall major discrepancy rate was only 0.8 percent, nearly one-half the miss rate for fellows,” he said.

Hospital of the University of Pennsylvania instituted 10 missed cased conferences as part of a three-week course residents take before they can take independent call.