Understanding and Confronting Our Mistakes: The Epidemiology of Error in Radiology and Strategies for Error Reduction

Published Online:https://doi.org/10.1148/rg.2015150023

Radiologists’ errors frequently contribute to missed and delayed diagnoses; understanding these errors and their underlying causes is an urgent priority to develop effective strategies for error reduction and prevent patient harm.

Arriving at a medical diagnosis is a highly complex process that is extremely error prone. Missed or delayed diagnoses often lead to patient harm and missed opportunities for treatment. Since medical imaging is a major contributor to the overall diagnostic process, it is also a major potential source of diagnostic error. Although some diagnoses may be missed because of the technical or physical limitations of the imaging modality, including image resolution, intrinsic or extrinsic contrast, and signal-to-noise ratio, most missed radiologic diagnoses are attributable to image interpretation errors by radiologists. Radiologic interpretation cannot be mechanized or automated; it is a human enterprise based on complex psychophysiologic and cognitive processes and is itself subject to a wide variety of error types, including perceptual errors (those in which an important abnormality is simply not seen on the images) and cognitive errors (those in which the abnormality is visually detected but the meaning or importance of the finding is not correctly understood or appreciated). The overall prevalence of radiologists’ errors in practice does not appear to have changed since it was first estimated in the 1960s. The authors review the epidemiology of errors in diagnostic radiology, including a recently proposed taxonomy of radiologists’ errors, as well as research findings, in an attempt to elucidate possible underlying causes of these errors. The authors also propose strategies for error reduction in radiology. On the basis of current understanding, specific suggestions are offered as to how radiologists can improve their performance in practice.

©RSNA, 2015


  • 1. Berner ES, Graber ML. Overconfidence as a cause of diagnostic error in medicine. Am J Med 2008;121(5 suppl):S2–S23. Crossref, MedlineGoogle Scholar
  • 2. Wachter RM. Why diagnostic errors don’t get any respect: and what can be done about them. Health Aff (Millwood) 2010;29(9):1605–1610. Crossref, MedlineGoogle Scholar
  • 3. Abujudeh HH, Boland GW, Kaewlai R, et al. Abdominal and pelvic computed tomography (CT) interpretation: discrepancy rates among experienced radiologists. Eur Radiol 2010;20(8):1952–1957. Crossref, MedlineGoogle Scholar
  • 4. Samei E, Krupinski E. Medical image perception. In: Samei E, Krupinski E, eds. The handbook of medical image perception and techniques. Cambridge, England: Cambridge University Press, 2010. Google Scholar
  • 5. Berlin L. Radiologic errors, past, present and future. Diagnosis 2014;1(1):79–84. CrossrefGoogle Scholar
  • 6. Revesz G, Kundel HL. Psychophysical studies of detection errors in chest radiology. Radiology 1977;123(3):559–562. LinkGoogle Scholar
  • 7. Siegle RL, Baram EM, Reuter SR, Clarke EA, Lancaster JL, McMahan CA. Rates of disagreement in imaging interpretation in a group of community hospitals. Acad Radiol 1998;5(3):148–154. Crossref, MedlineGoogle Scholar
  • 8. Donald JJ, Barnard SA. Common patterns in 558 diagnostic radiology errors. J Med Imaging Radiat Oncol 2012;56(2):173–178. Crossref, MedlineGoogle Scholar
  • 9. Kim YW, Mansfield LT. Fool me twice: delayed diagnoses in radiology with emphasis on perpetuated errors. AJR Am J Roentgenol 2014;202(3):465–470. Crossref, MedlineGoogle Scholar
  • 10. Kundel HL. Perception errors in chest radiography. Semin Respir Med 1989;10(3):203–210. CrossrefGoogle Scholar
  • 11. Quekel LG, Kessels AG, Goei R, van Engelshoven JM. Miss rate of lung cancer on the chest radiograph in clinical practice. Chest 1999;115(3):720–724. Crossref, MedlineGoogle Scholar
  • 12. Garland LH. On the scientific evaluation of diagnostic procedures. Radiology 1949;52(3):309–328. LinkGoogle Scholar
  • 13. Berlin L. Radiologic errors and malpractice: a blurry distinction. AJR Am J Roentgenol 2007;189(3):517–522. Crossref, MedlineGoogle Scholar
  • 14. Berlin L. Accuracy of diagnostic procedures: has it improved over the past five decades? AJR Am J Roentgenol 2007;188(5):1173–1178. Crossref, MedlineGoogle Scholar
  • 15. Brook OR, O’Connell AM, Thornton E, Eisenberg RL, Mendiratta-Lala M, Kruskal JB. Quality initiatives: anatomy and pathophysiology of errors occurring in clinical radiology practice. RadioGraphics 2010;30(5):1401–1410. LinkGoogle Scholar
  • 16. Pinto A, Brunese L. Spectrum of diagnostic errors in radiology. World J Radiol 2010;2(10):377–383. Crossref, MedlineGoogle Scholar
  • 17. Provenzale JM, Kranz PG. Understanding errors in diagnostic radiology: proposal of a classification scheme and application to emergency radiology. Emerg Radiol 2011;18(5):403–408. Crossref, MedlineGoogle Scholar
  • 18. Renfrew DL, Franken EA Jr, Berbaum KS, Weigelt FH, Abu-Yousef MM. Error in radiology: classification and lessons in 182 cases presented at a problem case conference. Radiology 1992;183(1):145–150. LinkGoogle Scholar
  • 19. Ashman CJ, Yu JS, Wolfman D. Satisfaction of search in osteoradiology. AJR Am J Roentgenol 2000;175(2):541–544. Crossref, MedlineGoogle Scholar
  • 20. Krupinski EA. Current perspectives in medical image perception. Atten Percept Psychophys 2010;72(5):1205–1217. Crossref, MedlineGoogle Scholar
  • 21. An online tutorial and review of CLAHE, Chapter 2. Teaching Website of the UCSF Radiology Department’s Tutorial on Portal Imaging. http://radonc.ucsf.edu/research_group/jpouliot/tutorial/HU/Lesson7.htm. Accessed April 3, 2015. Google Scholar
  • 22. Castellino RA. Computer aided detection (CAD): an overview. Cancer Imaging 2005;5(1):17–19. Crossref, MedlineGoogle Scholar
  • 23. Mallett S, Phillips P, Fanshawe TR, et al. Tracking eye gaze during interpretation of endoluminal three-dimensional CT colonography: visual perception of experienced and inexperienced readers. Radiology 2014;273(3):783–792. LinkGoogle Scholar
  • 24. Croskerry P. Clinical cognition and diagnostic error: applications of a dual process model of reasoning. Adv Health Sci Educ Theory Pract 2009;14(suppl 1):27–35. Crossref, MedlineGoogle Scholar
  • 25. Wilson TD, Brekke N. Mental contamination and mental correction: unwanted influences on judgments and evaluations. Psychol Bull 1994;116(1):117–142. Crossref, MedlineGoogle Scholar
  • 26. Graber ML, Kissam S, Payne VL, et al. Cognitive interventions to reduce diagnostic error: a narrative review. BMJ Qual Saf 2012;21(7):535–557. Crossref, MedlineGoogle Scholar
  • 27. Croskerry P, Singhal G, Mamede S. Cognitive debiasing 2: impediments to and strategies for change. BMJ Qual Saf 2013;22(suppl 2):ii65–ii72. Crossref, MedlineGoogle Scholar
  • 28. Rosen MA, Pronovost PJ. Advancing the use of checklists for evaluating performance in health care. Acad Med 2014;89(7):963–965. Crossref, MedlineGoogle Scholar
  • 29. Gawande A. The checklist manifesto: how to get things right. New York, NY: Metropolitan Books/Henry Holt, 2009. Google Scholar
  • 30. Leape LL, Shore MF, Dienstag JL, et al. Perspective: a culture of respect. II. Creating a culture of respect. Acad Med 2012;87(7):853–858. Crossref, MedlineGoogle Scholar
  • 31. Bruno MA, Petscavage-Thomas JM, Mohr MJ, Bell SK, Brown SD. The “open letter”: radiologists’ reports in the era of patient web portals. J Am Coll Radiol 2014;11(9):863–867. Crossref, MedlineGoogle Scholar
  • 32. The Joint Commission National Patient Safety Goals. The Joint Commission Web site. http://www.jointcommission.org/standards_information/npsgs.aspx. Accessed February 2015. Google Scholar
  • 33. Rubin GD. Lung nodule and cancer detection in computed tomography screening. J Thorac Imaging 2015;30(2):130–138. Crossref, MedlineGoogle Scholar
  • 34. Bailey R, McNamara A, Sudarsanam N, Grimm C. Subtle gaze direction. ACM Trans Graph 2001;2(3):1–22. Google Scholar

Article History

Received: Feb 9 2015
Revision requested: Mar 20 2015
Revision received: Apr 7 2015
Accepted: Apr 9 2015
Published online: Oct 14 2015
Published in print: Oct 2015