What are the trends in malpractice litigation in medical imaging technologists and sonographers and why do they occur? A scoping review

BACKGROUND Medical errors are defined by Grober and Bohnen (2005, p. 42) as, “an act of omission or commission in planning or execution that contributes or could contribute to an unintended result”. Subsequently, jeopardization of patient safety and economic problems can occur, regardless of if the incident was adverse (Grober & Bohnen, 2005). Adverse events are caused by unforeseen medical incidents and may result in death or permanent disability (Wilson et al., 1995). The only in-depth retrospective quantitative study assessing the quality of the Australian healthcare system in 1992, revealed the rate of adverse events was 16.6% where 51% of these events were preventable out of 14,179 hospital admissions in New South Wales and South Australia (Wilson et al., 1995). Notably, 13.7% of patients resulted in permanent disability and 4.9% suffered death (Wilson et al., 1995). Radiologists face litigation due to radiological, external and psychological errors and each new modality introduces new reasons for litigation (Littlefair, 2015). Yasgur (2022) identified out of 29 medical specialties, radiology ranked ninth in malpractice lawsuit involvement. Many radiology claims were due to delayed or misdiagnosis, with the remaining claims involving complications from treatment, surgery, poor outcome or disease progression (Yasgur, 2022). Numerous studies revealed lawsuits against radiologists are primarily due to misdiagnosis or miscommunication, resulting in poor patient care (Biswas et al., 2023; Cannavale et al., 2013; Kwee & Kwee, 2020). Tarkiainen et al. (2021) conducted a retrospective study to survey patient injury claims relating to medical imaging (MI) in Finland from 1991-2017. Out of 1054 claims, most claims were related to mammography and screening mammography (29.8%), radiography (16.1%) and magnetic resonance imaging (MRI) (15.4%), while claims involving ultrasound and computed tomography (CT) were 9.8% and 5.9% respectively. Despite diagnosis-related errors (55.1%) being the most common reason for filing lawsuits, medical malpractice errors (36.3%) and improper examinations (6%) were also emphasized. In the United Kingdom, the total value of 10,284 clinical negligence claims in 2021/22 was £6.03 billion, where 4% of claims were related to radiology, making up only 1% (£60.3 million) of the total value (National Health Service Resolution, 2022). Harvey et al. (2016) conducted a quantitative study on the frequency and cost of radiology malpractice claims in the United States from 2008 to 2012 identifying out of 300,000 medical claims, 879 claims were related to radiology. 37.7% of radiology claims involved indemnity payments to the claimant with the median indemnity payment equating to $175,000. Staggeringly, the total paid loss (indemnity payment, defence cost and administrative costs) for all claims was $180.7 million with a median loss of $30,091 per case. Medical imaging examinations are performed by sonographers and medical imaging technologists (MITs), which include diagnostic radiographers and nuclear medicine technologists (NMTs). Diagnostic radiographers utilise ionising radiation to perform CT and projection radiography in a variety of clinical settings to generate diagnostic images (Medical Radiation Practice Board of Australia (MRPBA), 2019). In contrast, NMTs are required to prepare the radiopharmaceutical and conduct nuclear medicine examinations and therapies within their respective imaging modalities (MRPBA, 2019). MITs must be competent in performing MRI and/or ultrasound if required as part of their practice (MRPBA, 2019), while sonographers need to perform diagnostic ultrasound examinations with sound waves to generate images of various body systems (Australian Sonographer Accreditation Registry, 2023). In the radiology department, patient incident reports may occur due to miscommunication between radiology staff and patients, lack of radiographic and/or pathological knowledge and improper imaging examinations (Wallin et al., 2018). Errors may occur during the preprocedural, procedural and postprocedural phases of the general radiography imaging cycle for radiographers (Zhou et al., 2015). During the preprocedural phase, wrong examination, wrong anatomical side, patient misidentification and request form errors may occur, while the procedural phase is associated with radiation incidents and repeats of plain radiographs (Zhou et al., 2015). Kjelle et al. (2021) revealed radiographers rejected or repeated radiographs due to suboptimal positioning, collimation, centering, artefacts, and exposure errors. These are examples of radiographic errors that could be performed by radiographers, creating possible avenues for patient complaints and misdiagnosis. Multidetector CT is complex as it requires appropriate CT acquisition parameters (collimation, reconstruction interval, etc.) and determining the relevant anatomical volume to be covered concerning the clinical question (Mazzei & Volterrani, 2015). Therefore, modifying CT examinations to tailor both the patient’s characteristics and the specific pathology being investigated while minimising dose to obtain diagnostic images can be challenging (Mazzei & Volterrani, 2015). One Saudi Arabian study concluded MRI technologists lack the education and knowledge in identifying MRI quality errors and suggesting appropriate correction techniques (Alsharif et al., 2016), making the identification of potential pathologies difficult due to poor image quality. Mammographers encounter challenges in optimising technical and radiographic techniques to produce diagnostic images, while minimising pain caused by breast compression during mammograms (Breast Screen South Australia, 2023; Metsälä et al., 2017). This may exacerbate errors in mammogram interpretations, which is already difficult as breast tissue composition varies among different women, making it difficult to distinguish abnormal growths from normal tissue (National Institute of Biomedical Imaging and Bioengineering, 2023). Zylstra et al. (2005) identified between 1999 and 2004, the aggregate indemnity payment was over $47 million from 132 breast cancer cases involving misdiagnosis and inadequate follow-up, which are still common reasons for filing litigation claims in recent years (Tarkiainen et al., 2021). Regarding NMTs, errors involving medication/IV fluids mainly involved omitted medicine or dose, while incorrect clinical administrations and clinical procedures mainly involved wrong patients and incomplete examinations respectively (Kasalak et al., 2020). Benacerraf (2004) highlights that ultrasound examinations are operator dependent and require adequate experience to perform coherent examinations. Common sources of error relating to the sonographer’s expertise include inadequate knowledge of the ultrasound equipment, failure to optimise images, usage of inappropriate probes, lack of communication with the patient and over-estimation of one’s capabilities (Farina & Sparano, 2012; Pinto et al., 2013). Between 1985 and the early 2000s, there was an upward trend in the number of litigation cases relating to ultrasound, with a survey study revealing that many sonographers believed obstetrics was the most likely area to result in litigation (Harrison & Mitcalf, 2003). This is further supported by Sanders (2003), who identified common reasons for filing litigation claims in obstetric and gynaecologic ultrasound were due to misdiagnosis, misinterpretation of images, the invention of lesions, delay in communicating findings to physicians, cases involving sonographers (particularly alleged sexual assault with the use of the vaginal probe) and invasive procedures done incorrectly due to improper ultrasound guidance. With advances in technology and rigorous protocols for practice, it is not clear if there have been any recent changes in trends for sonographer litigation. Preliminary searches identified an abundance of literature concerning the types of errors and challenges involved for MITs. However, the direct link between errors and malpractice litigation for MITs is poorly understood. Identification of potential causes of litigation also has implications for policy and practice, where more rigorous protocols can be developed and implemented to improve safety for patient centred care. Hence, this research seeks to minimise the knowledge gap in the current literature on the causes of malpractice litigation. AIM The aim of this scoping review is to map the existing literature about the common trends in malpractice litigation of allied health professionals working in MI, including identifying the causes of malpractice litigation. To reduce the knowledge gap surrounding this topic, the research question, “What are the trends in malpractice litigation in medical imaging technologists and sonographers and why do they occur?” will allow a detailed scope of this study.