les erreurs en imagerie - sfrnet.org · 2019-03-19 · 10 satisfaction of search other finding (s)...

LES ERREURS EN IMAGERIEJEAN-LUC SARRAZIN

ERREUR ?

• DIAGNOSTIC MANQUÉ, FAUX OU RETARDÉ DÉMONTRÉ PAR UN EXAMEN ULTÉRIEUR (GARLAND, RADIOLOGY 1949)

• ERREUR : IMPLIQUE UNE MAUVAISE PRISE EN CHARGE DU PATIENT (RSNA 2007)

ERREURS EN IMAGERIE

IMAGES ET COMPTE-RENDU, BASE ET PREUVE DE L’ERREUR, PÉRENNES

COMBIEN D’ERREURS ?

• 44 000 À 99 000 MORTS PAR AN AUX USA DU FAIT D’ERREURS MÉDICALES

• TAUX D’ERREURS DANS LA PRATIQUE QUOTIDIEN : 3 À 5%

• APRÈS AUTOPSIE, TAUX DE DIVERGENCE DIAGNOSTIQUES MAJEURS : 20%

• TAUX DE DIAGNOSTICS MANQUÉS, INCORRECT OU RETARDÉS 10 -15%

COMMENT LES ÉVALUER ?

• AUTOPSIE : RÉFÉRENCE FIABLE, RADICALE …MAIS RARE

• PEER REVIEW :

• SOUVENT DANS DES DOMAINES DIFFICILES

• POSE LE PROBLÈME DE LA DIVERGENCE D’INTERPRÉTATION VS ERREUR

• RELECTURE DE SCANNERS ABDOMINO PELVIENS : DÉSACCORD..

• 30% INTER OBSERVATEURS

• 25% INTRA OBSERVATEURS

• TAUX DE DISCORDANCES ENTRE 0,8 ET 58% DANS LA LITTÉRATURE

• TAUX D’ERREUR ENTRE 10 ET 15%

• TAUX D’AUTO RECONNAISSANCE D’ERREUR 0,8%LR Brigham AJR 2015; 205:1230–1239

QUELLES MODALITÉS ?

YW Kim AJR 2014; 202:465–470

COMMENT LES CLASSER POUR LES COMPRENDRE ET LES ÉVITER…?

Cause %

1 Complacency Error mix: over reading, misinterpretation: false positive 0.9

2 Faulty reasoning Abnormal finding attributed to a wrong cause. Misleading 9.0

3 Lack of knowledge … 3.0

4 Under reading Finding is missed 42.0

5 Poor communication Report is correct but message fails to reach the clinician NA

6 Technique Limitations of examination or technique 2.0

7 Prior examination Failure to consult prior examinations/alliterative bias 5.0

8 History Inaccurate clinical history/framing bias 2.0

9 Location Lesion missed because outside the area of interest 7.0

10 Satisfaction of search Other finding (s) missed: failure to continue to search 22.0

11 Complication Procedure 0.5

12 Report Overreliance of the radiology report of previous exam. 6.0

YW Kim AJR 2014; 202:465–470 MA Bruno RadioGraphics 2015; 35:1668–1676

Contexte

- Demande d’examen

- Antécédents

- Précédents examens

Technique

- Incidences

- Injection Séquences

- Contre-indications..

Lecture

Analyse Raisonnement

Rendu

- Compte-rendu

- Téléphone

- Films, CD..

Erreurs procédurales

Erreurs de détection

Erreurs d’interprétation

Erreurs de communication

DÉMARCHE EN IMAGERIE ET ERREURS

ERREURS DE PROCÉDURE

CONTEXTE

• DEMANDE D’EXAMEN INCOMPLÈTE,

IMPRÉCISE, INADAPTÉE ….

• MÉCONNAISSANCE DES ANTÉCÉDENTS

(CONTEXTE, CHIRURGIE, TRAITEMENT)

• MÉCONNAISSANCE DES EXAMENS

ANTÉRIEURS

TECHNIQUE

• CHOIX DE LA MODALITÉ

• CHOIX DU PROTOCOLE

• RÉGION À EXPLORER

• CONTRE-INDICATIONS, PRÉCAUTIONSCause %













16%

Patient de 60 ans

Antécédents de dissection CI droite

Céphalées pulsatiles

Patient de 60 ans

Antécédents de dissection CI droite

Acouphènes pulsatiles gauches

ERREURS DE DÉTECTION

• ANOMALIE PEU VISIBLE

• RYTHME D’INTERPRÉTATION TROP RAPIDE

• FATIGUE DU RADIOLOGUE

• DISTRACTIONS COMME APPELS TÉLÉPHONIQUES, SMS, MAILS, INTERNET..

• SATISFACTION DE LA RECHERCHE : LA MISE EN ÉVIDENCE D’UNE ANOMALIE ENTRAINE L’ARRÊT DE LA

LECTURE ET MANQUE UNE DEUXIÈME ANOMALIE

• INEXPLICABLE…..

TOUS LES RADIOLOGUES SONT CONCERNÉS (TOUS NIVEAUX)

Cause %













42%

Femme de 78 ans

Bilan de Névralgie cervico brachiale gauche.

IRM du Rachis cervical

Homme de 71 ans

Surveillance annuel chez un patient opéré il y a 6 ans polypes vésicaux

2017 2018

Compte-rendu : « Normal »

Cause %













Figure 1.

Gorilla opacity increased from 50 to 100%, then back down to 50% over the course of 5

frames within the chest CT scan.

Drew et al. Page 6

Psychol Sci . Author manuscript; available in PMC 2014 September 01.

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“The invisible gorilla strikes again: Sustained inattentional

blindness in expert observers”

Trafton Drew, Melissa L. H. Vo, and Jeremy M. Wolfe

Trafton Drew: [email protected]

Abstract

We like to think that we would notice the occurrence of an unexpected yet salient event in our

world. However, we know that people often miss such events if they are engaged in a different

task, a phenomenon known as “inattentional blindness.” Still, these demonstrations typically

involve naïve observers engaged in an unfamiliar task. What about expert searchers who have

spent years honing their ability to detect small abnormalities in specific types of image? We asked

24 radiologists to perform a familiar lung nodule detection task. A gorilla, 48 times larger than the

average nodule, was inserted in the last case. 83% of radiologists did not see the gorilla. Eye-

tracking revealed that the majority of the those who missed the gorilla looked directly at the

location of the gorilla. Even expert searchers, operating in their domain of expertise, are

vulnerable to inattentional blindness.

Introduction

When engaged in a demanding task, attention can act like a set of blinders, making it

possible for salient stimuli to pass unnoticed right in front of our eyes (Neisser & Becklen,

1975). This phenomenon of “sustained inattentional blindness” is best known from Simons

and Chabris’ (1999) study in which observers attend to a ball-passing game while a human

in a gorilla suit wanders through the game. Despite having walked through the center of the

scene, the gorilla is not reported by a substantial portion of the observers ( http://

www.theinvisiblegorilla.com/videos.html). Does inattentional blindness (IB) still occur

when the observers are experts, highly trained on the primary task? There is some evidence

that expertise mitigates the effect. For example, Memmert (Memmert, 2006) found a

decreased the rate of IB for basketball players who were asked to count the number of

basketball passes in an artificial game. On the other hand, when Potchen (2006) showed

radiologists chest x-rays with a clavicle (collarbone) removed, roughly 60% of radiologists

failed to notice when they were reviewing cases as if for an annual exam. Finally, a recent

observational case report documented a case where a misplaced femoral line was not

detected by variety of health care professional who evaluated the case (Lum, Fairbanks,

Pennington, & Zwemer, 2005).

Both of these instances of apparent IB in the medical setting occurred in single-slice medical

images. Modern medical imaging technologies like Magnetic Resonance Imaging (MRI),

Computed Tomography (CT) and Positron Emission Tomography (PET) are increasingly

complex: the single image of a chest x-ray has been replaced with hundreds of slices of

chest CT scan. It is therefore important to study whether IB occurs in these modern imaging

modalities. From the point of view of IB, these situations are interesting because the

observer is actively interacting with the stimulus; in this case, scrolling through a stack of

Correspondence to: Trafton Drew, [email protected] .

NIH Public AccessAuthor ManuscriptPsychol Sci . Author manuscript; available in PMC 2014 September 01.

Published in final edited form as:

Psychol Sci . 2013 September ; 24(9): 1848–1853. doi:10.1177/0956797613479386.

NIH

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or M

an

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A A

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t

“The invisible gorilla strikes again: Sustained inattentional

blindness in expert observers”

Trafton Drew, Melissa L. H. Vo, and Jeremy M. Wolfe

Trafton Drew: [email protected]

Abstract

We like to think that we would notice the occurrence of an unexpected yet salient event in our

world. However, we know that people often miss such events if they are engaged in a different

task, a phenomenon known as “inattentional blindness.” Still, these demonstrations typically

involve naïve observers engaged in an unfamiliar task. What about expert searchers who have

spent years honing their ability to detect small abnormalities in specific types of image? We asked

24 radiologists to perform a familiar lung nodule detection task. A gorilla, 48 times larger than the

average nodule, was inserted in the last case. 83% of radiologists did not see the gorilla. Eye-

tracking revealed that the majority of the those who missed the gorilla looked directly at the

location of the gorilla. Even expert searchers, operating in their domain of expertise, are

vulnerable to inattentional blindness.

Introduction

When engaged in a demanding task, attention can act like a set of blinders, making it

possible for salient stimuli to pass unnoticed right in front of our eyes (Neisser & Becklen,

1975). This phenomenon of “sustained inattentional blindness” is best known from Simons

and Chabris’ (1999) study in which observers attend to a ball-passing game while a human

in a gorilla suit wanders through the game. Despite having walked through the center of the

scene, the gorilla is not reported by a substantial portion of the observers ( http://

www.theinvisiblegorilla.com/videos.html). Does inattentional blindness (IB) still occur

when the observers are experts, highly trained on the primary task? There is some evidence

that expertise mitigates the effect. For example, Memmert (Memmert, 2006) found a

decreased the rate of IB for basketball players who were asked to count the number of

basketball passes in an artificial game. On the other hand, when Potchen (2006) showed

radiologists chest x-rays with a clavicle (collarbone) removed, roughly 60% of radiologists

failed to notice when they were reviewing cases as if for an annual exam. Finally, a recent

observational case report documented a case where a misplaced femoral line was not

detected by variety of health care professional who evaluated the case (Lum, Fairbanks,

Pennington, & Zwemer, 2005).

Both of these instances of apparent IB in the medical setting occurred in single-slice medical

images. Modern medical imaging technologies like Magnetic Resonance Imaging (MRI),

Computed Tomography (CT) and Positron Emission Tomography (PET) are increasingly

complex: the single image of a chest x-ray has been replaced with hundreds of slices of

chest CT scan. It is therefore important to study whether IB occurs in these modern imaging

modalities. From the point of view of IB, these situations are interesting because the

observer is actively interacting with the stimulus; in this case, scrolling through a stack of

Correspondence to: Trafton Drew, [email protected] .

NIH Public AccessAuthor ManuscriptPsychol Sci. Author manuscript; available in PMC 2014 September 01.

Published in final edited form as:

Psychol Sci . 2013 September ; 24(9): 1848–1853. doi:10.1177/0956797613479386.

NIH

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PERCEPTION VISUELLE

Scanner pulmonaire

Recherche de nodules

297 coupes

5 coupes intégrant un.. Gorille

24 radiologues

20 ne décrivent pas le gorille

ERREUR D’INTERPRÉTATION

ANOMALIE VUE MAIS MAL INTERPRÉTÉE.

• MANQUE DE CONNAISSANCE

• MAUVAISE INFORMATION CLINIQUE

• BIAIS COGNITIF

• RECONDUITE D’UNE ERREUR PRÉALABLE.

Cause %













13%

« Eccentric target » Œdème

Aspect nécrotique

Pas de restriction

en diffusion

TOXOPLASMOSE

ERREURS COGNITIVES : QUELQUES BIAIS..

• BIAIS D’ANCRAGE : LA MISE EN ÉVIDENCE D’UNE PREMIÈRE ANOMALIE « EMPÊCHE »

L’INTÉGRATION D’AUTRES ANOMALIES

• BIAIS DE DISPONIBILITÉ : REFAIRE LE DIAGNOSTIC D’UNE PATHOLOGIE RÉCEMMENT

DIAGNOSTIQUÉE

• BIAIS DE CONFIRMATION : RECHERCHER TOUS LES ÉLÉMENTS QUI CONFIRMENT L’IMPRESSION

PREMIÈRE ET NÉGLIGER CEUX QUI VONT CONTRE CE DIAGNOSTIC.

ERREURS DE COMMUNICATION

• ABSENCE DE COMMUNICATION DIRECTE (URGENCE)

• COMPTE-RENDU MAL RÉDIGÉ

• VOCABULAIRE OU GRAMMAIRE PEU OU PAS ADAPTÉS

• CONCLUSION AMBIGUE

• RENDU : ERREURS FILM, CD…..

COMMENT LES ÉVITER ?

Erreurs procédurales




Demande

Pertinence (GBU….)

Critères HAS région anatomique, motif, Finalité.

Technique

Protocoles…


Environnement de travail…

Productivité

Mails, télephone, sms…

Laure


Progresser (incidentalomes, faux positifs..)

Éliminer les biais…

Douter…

Laureencore

..?


Valeur du compte-rendu

Mode de rendu : devenir des films, CD..

Manipulateurs, secrétaires…

COMMENT LES ÉVITER, LES ANNONCER, LES SURMONTER ?

La mortalité des patients est-elle associée au temps que le médecin d’un patient passe à jouer au golf (soit négativement, parce que les médecins libèrent du stress sur le terrain de golf, soit positivement en raison de la diminution de la disponibilité et du temps passé non consacré au développement des compétences cliniques)?

Les coûts des soins augmentent-ils et les résultats pour les patients empirent-ils dans les jours qui suivent une mauvaise partie de golf d’un médecin?

Est-ce le match-play au golf perdu le dimanche contre JLS par MZ (spécialiste inernationalement reconnu de l’imagerie du pancréas), qui l’a conduit à faire le lundi cette erreur (faux positif – tumeur calcifiée de la queue du pancréas) ??

Biais cognitif

Image tirée de la séance

« Le pancréas et ses sortilèges »

JFR 2011… MZ (!)

les erreurs en imagerie - sfrnet.org · 2019-03-19 · 10 satisfaction of search other finding (s)...

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