The Curse of the Red Dot

Name That Bone? Radiology images can be really tricky to correctly interpret, this can especially be so in the typical environment of a frantic ED......  which quite frankly is as far removed from the quiet, dark, undisturbed setting as you can get. As a result errors around x-rays are not uncommon.  Here's a quote from the Royal College of Radiologists that makes this very point; Error is inherent in radiology. The available evidence suggests an error rate in unselected radiology practice of between three and five percent. For certain types of specialist examination, where review by sub-specialists has occurred, the quoted error rate exceeds 30%. About 36 million radiological examinations take place in the NHS in England each year, the great majority of which receive a radiologist’s report. A conservative estimate therefore would suggest that close to one million radiological errors occur each year in the NHS. This equates to approximately 4500 a year in an average sized radiology department ie 90 a week. Near misses are even more common RCR Response to Duty of Candour Everyone who works in healthcare knows this.  Everyone tries hard to reduce this.  One of the simple measures most hospitals use is the so called 'red dot' system........... Situation -The Curse of the Red Dot Background A lady in her 60's with very poor mobility secondary to a stroke attended the ED with a history of falling during the night whilst visiting the toilet. She was struggling to mobilise at all, with pain in the left knee. She was seen in the ED and sent for X-ray. On her return the images were reviewed and checked with a senior doctor. The images were deemed to be normal and the patient was sent home with a diagnosis of a soft tissue injury. Radiology contacted the ED two days later to notify us of a missed fracture. On review of the films there was a  clear missed tibial plateau fracture and it was noted that the original image had been ‘red dotted’ by the radiographers

The patient was recalled and subsequent films showed further displacement of the fracture. The patient has been admitted for operative repair.

 1st presentation- Red dotted.. but looks ? normal...

......aha !

Assessment

Good care-  a junior doctor sought advice from a senior doctor In the ‘old days’ of hard copy films, appropriately trained radiographers would place a red dot sticker on films they thought were abnormal. This was a safety feature to reduce the chances of anomalies being missed. Digital images obviously cannot have stickers placed on them, so radiographers now write ‘red dot’ on the image. Just because a radiographer red dots a film does not mean it is definitely abnormal, however it should raise your suspicion and make you look ‘extra hard’

This lady had several images of her knee taken, whilst all were red dotted the fracture was much more clearly visible on some than others.

Recommendation

If you see a ‘red dot’ image  double check and triple check the image AND the patient If you still cannot see what the radiographer seems to be concerned about,  go and ask them what they think they are seeing, they might be wrong……………..but they might be right Make sure you look at all the images taken. Only one may show the abnormality. http://radiopaedia.org/articles/tibial-plateau-fracture http://emedicine.medscape.com/article/1249872-overview http://www.orthobullets.com/trauma/1044/tibial-plateau-fractures Unnecessary Additional Information The image of the radiologist reporting is a tad misleading- its a Sauropod fossil vertebra