Scientific Session 1 — Breast Imaging: Mammography

Scientific Session 15—General/Emergency RadiologyWednesdayResults: We assessed 2008 cases, 1021 prior to and 987 following thechange in CT protocol. Of these, 613 cases before (mean age, 52 years;age range, 18–97 years) and 611 cases after (mean age, 51.8 years; agerange, 17–104 years) the intervention were eligible for oral contrastmaterial and were included in our study. There was no significantdifference in mean age or gender distribution between the groups.Ninety-five percent received oral contrast material prior to the protocolchange and 42% thereafter. In our study group, mean patient time in theED decreased by 97 minutes (p < 0.001) after the protocol change (539min to 442 min). Time from order to CT scan decreased by an average of65 minutes (p < 0.001). Of postprotocol patients who did not receive oralcontrast material and had no acute findings on CT, none returned to theED within 72 hours as a result of a finding missed on initial CT. We are inthe process of evaluating a more recent 2-month time period to hopefullydemonstrate even further reduction in use of oral contrast material withmaintained accuracy as radiologists and emergency medicine physicianshave become more accustomed to the changed protocol.Conclusion: Reduction in the use of oral contrast material for abdominal CTin the ED may be successful in decreasing both the patient length of stay andthe time from order to CT scan without compromise in patient diagnosis.126. “Fool Me Twice:” Diagnostic Errors in Radiology WithEmphasis on Perpetuated ErrorsMansfield, L. 1 *; Kim, Y. 2 1. Brooke Army Medical Center, San Antonio,TX; 2. Tripler Army Medical Center, Honolulu, HIAddress correspondence to L. Mansfield (liem.mansfield@gmail.com)Objective: Diagnostic errors in radiology are often not recognized onsubsequent radiological examinations and are a result of multiple typesof diagnostic errors.Materials and Methods: Six hundred fifty-six radiological examinationswith delayed diagnoses were collected from July 2002 to January 2010 atour institution. Each case was reviewed by two radiologists and the diagnosticerrors were classified according to our modified scheme. When appropriate,more than one type of error was assigned to each case. Data collectedinclude the number of days elapsed between the initial examination on whichthe diagnosis was missed and the subsequent examination on which the correctdiagnosis was made, the imaging technique on which the diagnosis wasmissed, the imaging technique on which the correct diagnosis was made, andwhether the diagnosis was missed on subsequent radiologic examinations.Results: There were a total of 1279 diagnostic errors. The range of dayselapsed was 0–4611 days, with an average of 251 days. The number oferrors as a percentage of total errors was type 1, 11 (1%); 2, 110 (9%); 3,39 (3%); 4, 535 (42%); 5, 1 (~ 0%); 6, 29 (2%); 7, 69 (5%); 8, 20 (2%); 9,92 (7%); 10, 288 (23%); 11, 6 (