One in seven patients with a recommended follow-up scan had a diagnostic error, mostly from delay

Design

Retrospective quality-improvement study with trained annotation

Population

185 adults with abdominal imaging and a recommendation for further imaging

Primary outcome

Proportion with at least one process-related diagnostic error

Effect

14.6% (95% CI 10.2% to 20.4%); leading factor delay in performing the ordered test

This quality-improvement study from a US academic health system took a random sample of adults whose abdominal imaging in 2022 ended with a recommendation for further imaging. Trained annotators, checked against two abdominal radiologists, reviewed 185 records using a process-error taxonomy.

At least one diagnostic error occurred in 14.6% (27 of 185; 95% CI 10.2% to 20.4%). The leading contributory factor was delay in performing the ordered test. Agreement between annotators and the specialist reference improved from 61% to 80% after four rounds of training.

The finding shifts attention from the reading room to the gap after the report. A recommendation that is correct but not acted on in time is still a diagnostic error. Closed-loop systems — a tracking list, a named owner and an alert when the test is overdue — are the fix, and they sit with departments and hospitals, not individual radiologists.

• Set up a tracked list of all follow-up imaging recommendations in your department
• Assign responsibility for chasing overdue recommended studies
• Alert the requesting clinician when a recommended study is overdue
• Audit a sample of recommendations each quarter for completion and timeliness
• Include patients in the loop: tell them a follow-up scan has been advised

Why it matters

It locates a large share of imaging-related diagnostic error after the report is signed.

Don't overread it

A single-institution quality review of 185 patients; the error rate elsewhere may differ.

The statistics, in plain English

14.6% with an interval of 10.2% to 20.4% means somewhere between one in ten and one in five such patients may be affected in a similar system.

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