We read with interest the recent discussion in the journal about wrong-side surgery.1,2 Systems are needed to ensure that the correct site and side are clearly indicated before surgery to reduce the occurrence of this surgical error. Of the numerous guidelines offered by the American College of Surgeons to reduce wrong-site surgery,1 we found the one about reviewing relevant records and imaging studies of interest to us.
As radiologists, identifying the correct site and side of an abnormality is of paramount concern to us. Mark Bernstein mentions a few reports about incorrect labelling of laterality on CT scans and chest radiographs.2 We wish to share an example of erroneous laterality identification on a recent nuclear medicine study.
A woman with hip pain was referred for a bone scan of the pelvis. The images showed abnormal increased uptake of the radiopharmaceutical in the medial aspect of the right femur below the lesser trochanter. This corresponded to the side of the patient’s reported pain. The dictated report, however, stated that the abnormality was in the left femur. This resulted from the incorrect marking of the anterior and posterior projections of the pelvis that was apparently not detected by the attending physician and radiology resident when the study was read and dictated. A few days later, a technician in nuclear medicine brought the matter to my (J.B.S.) attention. I was informed that a resident physician other than the one who dictated the original report had been informed of the error but was unwilling to correct the problem. Realizing the gravity of what the primary physician or orthopedist might do (i.e., additional imaging studies or possibly biopsy), I called both physicians that day to inform them of the error, and an addendum was dictated to document the correction of the error.
Although it would be helpful for surgeons to review imaging studies and reports beforehand, the usefulness of this suggestion presupposes that the reports and labels on the images themselves correctly specify the side of an abnormality. Although such wrong-site errors probably carry more serious implications for surgeons, radiologists should also be concerned with this problem when dictating reports. In addition to teaching physicians-in-training systems to avoid committing this type of medical error, we are equally concerned that they need to understand their potential culpability for not correcting such errors brought to their attention.