Researchers re-imagine X-ray errors

Researchers re-imagine x-ray error detection through patient photos

Emory University and Georgia Institute of Technology researchers have re-imagined X-ray conduct in such a way that so-called “wrong-patient” errors could be reduced five-fold. Their remedy? A photo shoot, of course.

"X-rays can look alike, and if one patient's images are confused with another before the radiologist sees them, it can be difficult for the radiologist to determine there is a mismatch," said Srini Tridandapani, MD, of Emory University and an author of the study, in a news release.

Tridandapani and fellow investigators employed the expertise of 10 radiologists and asked the specialists to interpret a series of X-ray images — some alone, others with accompanying headshots of the corresponding patients. For the 20 images sans patient mugshots, the error-detection rate when trying to locate the two to four mismatched X-rays in each set was only 13 percent, compared to the 64 percent when patient images were included.     

As the radiologists were unaware that they could use the patient photographs as a means to identify mismatched X-ray images, most admitted to ignoring them in the first study. Thus, Tridandapani conducted a second study with five radiologists and made sure they knew to use the photographs as an identification aide. The error-detection rate for the second study rose to 94 percent and the interpretation rate also went down.

"I estimate that about 1 out of 10,000 examinations have wrong-patient errors," Tridandapani said. "It occurred to me that we should be adding a photograph to every medical imaging study as a means to correct this problem after I received a phone call, and a picture of the caller appeared on my phone. The picture immediately identified for me who the caller was," he said.

Although for the study, additional personnel were employed to take a headshot of patients directly after they received their X-ray, Tridandapani noted that he and his colleagues have established a system where a camera can be attached to a portable X-ray machine and therefore nullify the need for additional staff members to partake in the process.

The study is set to be presented at the American Roentgen Ray Society (ARRS) annual meeting on April 15 in Washington, D.C.