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Fig. 9 | Insights into Imaging

Fig. 9

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

Fig. 9

Technique-related (Type 6) error with poor communication. An 88-year-old female patient using an injectable anticoagulant was admitted to the emergency room with right lower quadrant pain. No finding to explain the symptom was observed on abdominal CT (a). Right inguinal swelling developed during follow-up and inguinal US revealed a large hematoma in this region. When the abdominal CT was evaluated retrospectively, it was noticed that, apart from the sections examined by the on-duty radiologists, two more series consisting of only 10–15 axial slices showing inguinal regions were separately uploaded to the PACS together with their coronal reformats (b, c). It was later learned that the CT technician had difficulty adjusting the field of view and had to take a few extra slices to cover the level of the symphysis pubis. However, he did not inform the on-call radiologists about this situation. Since the images were sent to the PACS piece by piece due to a technical error, and the radiologists were not informed about the problem due to lack of communication, the diagnosis of a clearly seen right inguinal hematoma was delayed (red arrows, b, c, d)

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