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Ensuring patient safety: a comprehensive approach to radiological errors.

Shoichi Maeda1, Eri Ishikawa1,2, Jay Starkey3,4

  • 1Medical Ethics and Patient Safety Laboratory, Keio Research Institute at SFC, Keio University Shonan Fujisawa, Fujisawa, Japan.

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Summary

Radiologic errors stem from human and systemic issues. This study proposes a model combining ethical transparency (disclosure and apology) with system redesign (Just Culture, human factors engineering) for improved patient safety.

Keywords:
ApologyLegalMedicolegalMissesRadiological errorRadiologyRadiology ethics

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Area of Science:

  • Medical error analysis
  • Patient safety research
  • Radiology quality improvement

Background:

  • Radiologic errors result from complex interactions between human factors and systemic vulnerabilities.
  • Missed renal masses due to fatigue represent a critical area for safety improvement in diagnostic imaging.
  • Current approaches often fail to integrate ethical considerations with robust system redesign.

Purpose of the Study:

  • To propose a comprehensive model for addressing radiologic errors.
  • To integrate ethical transparency (disclosure and apology) with system redesign principles.
  • To foster a sustainable culture of safety and patient-centered improvement in radiology.

Main Methods:

  • Case study analysis of a fatigue-related missed renal mass.
  • Integration of Just Culture principles and human factors engineering for system redesign.
  • Development of practical guidance for disclosure, apology, and institutional learning.

Main Results:

  • A proposed model linking ethical transparency and system redesign for error management.
  • Identification of common sources of malpractice in radiology.
  • Strategies for transforming individual errors into systemic learning opportunities.

Conclusions:

  • Ethical transparency and system redesign are complementary and essential for patient safety.
  • Implementing Just Culture and human factors engineering can mitigate radiologic errors.
  • Institutional commitment to learning from errors drives patient-centered improvements in radiology.