Heuristics and Cognitive Error in Medical Imaging

Itri, Jason N.; Patel, Sohil H.

doi:10.2214/ajr.17.18907

Cited by 64 publications

(53 citation statements)

References 41 publications

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“…The model states that there are various approaches to problem solving along a spectrum, with unconscious intuitive approaches at one end and deliberate analytical approaches at the other. The intuitive approach, also known as type 1 or fast thinking, can be characterized as a form of pattern recognition leading to an automatic and immediate diagnosis using heuristics (eg, mental shortcuts) (4,(11)(12)(13)(14)(15). The deliberate approach, also known as type 2 or slow thinking, occurs when an abnormal pattern or finding is identified but not immediately recognized, requiring deliberate reasoning and problem solving.…”

Section: Why Errors Occur Dual Process Theory and Cognitive Biasesmentioning

confidence: 99%

Fundamentals of Diagnostic Error in Imaging

et al. 2018

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Imaging plays a pivotal role in the diagnostic process for many patients. With estimates of average diagnostic error rates ranging from 3% to 5%, there are approximately 40 million diagnostic errors involving imaging annually worldwide. The potential to improve diagnostic performance and reduce patient harm by identifying and learning from these errors is substantial. Yet these relatively high diagnostic error rates have persisted in our field despite decades of research and interventions. It may often seem as if diagnostic errors in radiology occur in a haphazard fashion. However, diagnostic problem solving in radiology is not a mysterious black box, and diagnostic errors are not random occurrences. Rather, diagnostic errors are predictable events with readily identifiable contributing factors, many of which are driven by how we think or related to the external environment. These contributing factors lead to both perceptual and interpretive errors. Identifying contributing factors is one of the keys to developing interventions that reduce or mitigate diagnostic errors. Developing a comprehensive process to identify diagnostic errors, analyze them to discover contributing factors and biases, and develop interventions based on the contributing factors is fundamental to learning from diagnostic error. Coupled with effective peer learning practices, supportive leadership, and a culture of quality, this process can unquestionably result in fewer diagnostic errors, improved patient outcomes, and increased satisfaction for all stakeholders. This article provides the foundational elements for implementing this type of process at a radiology practice, with examples to help radiologists and practice leaders achieve meaningful practice improvement. ©

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Section: Why Errors Occur Dual Process Theory and Cognitive Biasesmentioning

confidence: 99%

Fundamentals of Diagnostic Error in Imaging

et al. 2018

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“…This study focused on the perceptual errors made by ED physicians, which occur when a physician fails to identify the abnormality or overcalls an abnormality . Perceptual interpretation errors may be the result of diminished content expertise or the influence of cognitive biases on image interpretation . A lack of content expertise may explain, for example, why interpretation errors are more likely to occur in the joint, an area of higher radiographic complexity .…”

Section: Discussionmentioning

confidence: 99%

“…This, alongside bringing radiographs to the emergency physician for interpretation with no radiology overread during the ED visit, significantly reduced ED physician bedside false‐negative errors . Furthermore, to combat the influence of cognitive biases on image interpretation, especially in cases of low clinical suspicion of a fracture, physicians can use metacognitive training that encourages reflective thinking and self‐questioning of a diagnosis to minimize missing or underdiagnosing fractures . Ultimately, promising artificial intelligence solutions that will aid physician imaging diagnoses may also serve to reduce these types of bedside errors …”

Section: Discussionmentioning

confidence: 99%

“…33 Perceptual interpretation errors may be the result of diminished content expertise or the influence of cognitive biases on image interpretation. 32,34 A lack of content expertise may explain, for example, why interpretation errors are more likely to occur in the joint, an area of higher radiographic complexity. 2,3 The variables of low pretest probability of a fracture or a low patient-reported pain score were also found to predict pediatric MSK radiograph interpretation errors.…”

Section: Discussionmentioning

confidence: 99%

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Adverse Events from Emergency Physician Pediatric Extremity Radiograph Interpretations: A Prospective Cohort Study

Al-Sani

Prasad

Panwar

et al. 2019

Academic Emergency Medicine

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Objectives We determined how often emergency physician pediatric musculoskeletal (MSK) radiograph interpretations were discordant to that of a radiologist and led to an adverse event (AE). We also established the variables independently associated with this outcome. Methods This prospective cohort study was conducted in an urban, tertiary care children's emergency department (ED). We enrolled children who presented to an ED with an extremity injury and received radiographs. ED physicians documented their radiograph interpretation, which was compared to a radiology reference standard. Patients received telephone follow‐up and had institutional medical records reviewed in 3 weeks. An AE occurred if there were clinical sequelae and/or repeat health care visits due to a delay in correct radiograph interpretation. Results We enrolled 2,302 children (mean [±SD] age = 9.0 [4.4] years; 1,288 (56.0%) male]. Of these, 180 (7.8%; 95% confidence interval = 6.8 to 9.0) ED physician discordant interpretations resulted in an AE. Specifically, there were no negative clinical outcomes; however, relative to cases diagnosed correctly at the index ED, patients whose fracture was not initially identified encountered 77.2% more subsequent ED visits, while those falsely diagnosed with a fracture experienced 41.5% additional orthopedic clinic visits. Odds of an ED discrepant interpretation was significantly higher if a physician’s pretest probability of a fracture was ≤ 20% versus> 20% (adjusted odds ratio [aOR] = 1.6), patient’s pain score was ≤ 2 versus> 2 (aOR = 1.6), and injury was located in a joint versus other location (aOR = 1.7). Conclusions Emergency physician discordant pediatric MSK radiograph interpretations that resulted in an AE occurred with regular frequency in a pediatric ED setting. AEs were primarily an increase in subsequent health care visits. Importantly, a low clinical suspicion for a fracture or injury located in the joint were risk factors for ED physician discordant interpretations.

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“…A systematic deviation from the norm in perceptual judgment or reasoning is known as a cognitive bias. 7 One clinically significant source of cognitive bias is confirmation bias, which occurs when information about a patient predisposes a clinician to expect, and consequently seek out or interpret, available information to confirm an initial diagnostic hypothesis. 8 An initial diagnostic hypothesis can be affected by the accuracy of a referring diagnosis 9 and/or case history.…”

Section: Introductionmentioning

confidence: 99%

Does the accuracy of case history affect interpretation of videolaryngostroboscopic exams?

et al. 2019

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Objective To determine the effect of initial diagnostic hypotheses on clinicians’ 1) detection and perceived severity of abnormalities, and 2) clinical impressions and treatment recommendations for individuals with and without voice disorders following interpretation of videolaryngostroboscopy (VLS). Methods Thirty‐two experienced speech‐language pathologists and otolaryngologists specializing in voice disorders read case histories prior to interpreting exams. Case histories suggested specific accurate or inaccurate laryngeal diagnoses, or a control scenario that suggested a normal larynx. The effects of the accuracy of case histories on perceived severity of associated visual‐perceptual parameters, clinical impressions, and treatment recommendations were examined. Results Significant increases in perceived severity of posterior laryngeal appearance (P < 0.05) and mucosal wave (P < 0.02) were observed when these abnormalities were suggested by case histories. Overall agreement with clinical impressions improved from 49% to 72% when the case history was consistent with the examination. Case histories (accurate and inaccurate) indicating voice symptoms predicted recommendations for treatment above and beyond that of VLS presentation alone, P < 0.001. Conclusion Case histories suggesting specific abnormalities significantly affected severity ratings for two of three associated visual‐perceptual parameters selected as primary outcome measures. Accurate case histories suggesting specific abnormalities increased the probability of detection and perceived severity. Inaccurate case histories led to false‐positive findings and failures to detect abnormalities or to interpret them as less severe. Case histories affected visual‐perceptual judgments and contributed to decisions about clinical impressions and treatment. Level of Evidence 2b Laryngoscope, 130:718–725, 2020

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Heuristics and Cognitive Error in Medical Imaging

Cited by 64 publications

References 41 publications

Fundamentals of Diagnostic Error in Imaging

Fundamentals of Diagnostic Error in Imaging

Adverse Events from Emergency Physician Pediatric Extremity Radiograph Interpretations: A Prospective Cohort Study

Does the accuracy of case history affect interpretation of videolaryngostroboscopic exams?

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