Medical Imaging Errors Cry Out for Lean Improvements

We lean thinkers know that when errors or defects are widespread, the problem usually lies in flaws in the process, not with individual errors. Those flaws often involve a lack of training, or a lack of standard work to ensure something is done the same way every time.

That seems to be the case when it comes to medical imaging. According to DiagnosticImaging.com, insurer Blue Care Network hired consulting firm RadMetrics to study the work of imaging providers. They examined 3,794 studies from 100 providers, with disturbing results.

11% of the sample studies had significant quality defects that potentially led to missed pathology or inappropriate therapy. They included studies where the selected field-of-view made it impossible for the clinician to fully appreciate the presence or extent of disease. Ultrasound studies were performed with the wrong transducer. Prostate ultrasound was performed without an endorectal coil. Obsolete equipment produced spinal images so poor that the edge of the spinal facets could not be seen. Brain CT produced artifacts that mimicked brain tumors.

In addition, about 20 percent of the studies involved coding, compliance or billing mistakes.

By the way, credit should go to the Health Business Blog, which is where I first learned about the DiagnosticImaging report.

A lack of standard work procedures in the imaging industry has to be a key reason for this problem. Inadequate training is the flip side of the same issue.

I hope that whatever agencies or organizations are involved in the training or certification of radiologists and their businesses become aware of this problem and take steps to address it.