Skip to main content
Fig. 8 | Insights into Imaging

Fig. 8

From: Errors, discrepancies and underlying bias in radiology with case examples: a pictorial review

Fig. 8

Poor communication (type 5) error with attribution bias. A 27-year-old female patient with no known disease presented at the Emergency Department with abdominal discomfort. After the first evaluation, an abdominal CECT was performed (a, b). Bilateral lung bases were also partially involved in abdominal CECT (b). CT was reported as “free fluid in the pelvis (red arrows a), bilateral pleural effusion, interlobular septal thickenings, and bilateral central ground-glass opacities in lung bases” (b). Although these are well-known findings of cardiac congestion, they were not attributed to cardiogenic edema because of the patient’s age and clinical history. Instead, findings were only described without any comment or impression in the report, and clinicians were expected to read the report and evaluate findings. Six hours later, the patient became dyspneic and tachypneic. Contrast-enhanced thorax CT (c, d) revealed findings compatible with pulmonary edema (c) and enlarged left atrium (blue double-sided arrow, d). Echocardiography, performed to rule out cardiac abnormality, showed severe mitral stenosis, possibly due to rheumatic heart disease. Attribution bias due to the “young age, clear medical history and irrelevant symptoms of the patient” caused the radiologist to avoid making any comments about the possibility of cardiac congestion in the report. As a result, poor communication between the radiologist and clinicians due to the lack of necessary interpretation in the report caused a delay in diagnosis

Back to article page