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Denver Medical Imaging Center Denver, CO 80221
Rush North Shore Medical Center Rush Medical College Skokie, IL
60076
Question
Members of our large multispecialty radiology group are asked on a daily basis to review with referring physicians complex imaging studies on critically ill patients. Frequently we discover errors or omissions in the initial written interpretation. Are we legally and ethically obligated to issue a written addendum correcting the initial interpretation?
Answer
Dr. Orzel presents two questions: once apprised of an error or omission in an initial written interpretation of a radiologic study, should radiologists issue corrected reports? If so, how should these corrected reports be phrased? I shall address these questions in order.
The answer to the first question is clearly yes. This point is specifically covered in the ACR Standard for Communication: Diagnostic Radiology, revised January 2002, that states, "If requested to render an interpretation of an imaging study obtained at the same facility and previously reported, and a discrepancy is noted, an addendum should be rendered" [1].
Virtually every legal opinion and ethical commentary on the subject of whether radiologic errors, once discovered, should be divulged to the patient's physician and when appropriate, directly to the patient or patient's family, favor complete disclosure by the radiologist of all facts and information relevant to a patient's health or well-being [2, 3].
As to the second question: correction of an erroneous initial written radiologic interpretation is best accomplished by issuing a written addendum that is headed by the statement, "This report supersedes previous report." The addendum should be succinct, matter-of-fact, and nonjudgmental. I suggest that an opening sentence might be, "Re-review of radiologic study after discussion with Doctor X [name of referring physician if there was indeed a discussion] now reveals that...[state correct findings]." Depending on the circumstance, an alternative opening sentence might be "Re-review of radiologic study after being apprised of additional information now reveals..." In this way the reinterpreting radiologist is stating clearly that the new interpretation is based on new information and is making no comment as to whether the initial interpretation contained an error. Such words as "missed," "error," or "mistake," or such phrases as "should have been diagnosed" or "was obviously present but not seen" should be avoided. Doing so should minimize the potential for malpractice claims.
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