Finding each other’s (and our own) errors is a daily occurrence in this business. The question then becomes: What should I do about it? Some of us simply forge on ahead, and don’t let the prior reader know of his or her miss. Some of us call or email with details. Some mention the miss in the current report, with phraseology such as, “. . . in retrospect, this lesion was clearly present.” What these folks don’t realize is that to a plaintiff attorney, such language is tantamount to saying, “The idiot who read the prior study missed something a large as an elephant, but I, The Great Doctor OZ of Radiology, have saved the day.” You think I’m exaggerating? I wish.
After being the recipient of “the call” telling me I had missed something, I got to thinking of a better way to accomplish this distasteful task. I generally don’t make “the call” for a perceptual miss. Sometimes, the lesion hides from our vision, or the PACS skipped a slice, or the phone rang, or the clinicians wanted the study reviewed RIGHT NOW while the patient was still getting off the gantry, etc., etc. I really doubt there is much to be learned from getting poked with a sharp stick every time this happens.
That being said, it is doctrine that we can and should learn from our misses, and I firmly believe this to be true. So I have established a new blog, Dalai’s Missed Files (http://missedfiles.blogspot.com) as a safe-haven for us to share the misses we find in daily practice, our own, and those of others. Please send the pertinent image(s), ANONYMIZED (or I’ll do it for you) to me, and I will post them. Add a line or two of explanation if needed.
I would ask that you NOT tell the person that missed the finding that you have submitted it to the new blog, or I’ll probably receive a bunch of angry comments…(“I didn’t miss that!” “No one would have seen that!” “Dr. X is after me!”) I don’t need that grief, and I won’t post such things if I receive them. Ultimately, I would like to see the new blog become a regular stop for those surfing around for radiological information. I want to facilitate better understanding of our field and our perception, and occasional lack thereof.
Please send cases to doctordalai(AT)gmail.com, and visit Dalai’s Missed Files regularly.