Commentary on eight CT lessons that we learned the hard way: an analysis of current patterns of radiological error and discrepancy with particular emphasis on CT

摘要

"Discrepancy meetings are a sign of a well functioning department," (Maskell, pers. comm.) In 2007, the Standards Committee of The Royal College of Radiologists (RCR) produced guidance on how these meetings should be conducted1 because, although there is probably no absolutely right way to run them, there are plenty of wrong ways, which at worst can involve bullying, harassment, and blame. The whole benefit of these meetings lies in their educational value, and the individual and departmental knowledge gained about how and when things go wrong in order that error can be minimized, because we know that it will never be eliminated. What can we learn in general from such meetings? Well, humility about our own errors for a start, together with the relief of finding that everyone else makes them too. The authors of "Eight lessons we learned the hard way..."3 have, however, gone further and looked in detail at what was collectively learned over a period of time in their department's discrepancy meetings and collated the most common errors that emerged.