Emerg Radiol DOI 10.1007/s10140-014-1268-3
ORIGINAL ARTICLE
Radiology medical malpractice suits in gastrointestinal radiology: prevalence, causes, and outcomes Stephen R. Baker & Shivam Shah & Shanchita Ghosh
Received: 16 January 2014 / Accepted: 29 August 2014 # American Society of Emergency Radiology 2014
Abstract The purpose of this study is to determine the prevalence, causes, and outcomes of GI malpractice suits in a survey of 8,401 radiologists. The malpractice histories of 8,401 radiologists from 47 states were evaluated from credentialing data of all radiologists participating in the network of One Call Medical Inc. Thirty-two percent of radiologists were defendants in at least one malpractice suit. Of the 4,073 total claims, 346 (8.49 %) were related to the gastrointestinal system. The most frequent primary allegations were failure to diagnose, 65.9 %, and procedural complications, 17.1 %. The commonest missed diagnoses were malignancy, 31.6 %; pneumoperitoneum, 19.3 %; and appendicitis, 14.5 %. Payment to the plaintiff occurred in 75.8 % of claims pertinent to cancer, 73.2 % for missed pneumoperitoneum, and 62.5 % related to appendicitis. Of cases in which a ruling was made in favor of the plaintiff, median payments for pneumoperitoneum was $215,000, for primary cancer $200,000, and for appendicitis $60,000. Among procedurally related errors resulting in judgment against a defending radiologist, 78.6 % of claims regarding retained foreign body, Advances in knowledge Malpractice claims against radiologists with respect to gastrointestinal diseases comprise 8.49 % of all radiology malpractice claims. Errors in diagnosis were the most frequent reason for a claim with failure to detect colon cancer and pneumoperitoneum the most common causes. Overall, more than 70 % of gastroenterology lawsuits against radiologists resulted in resulted in payments to the plaintiff. S. R. Baker : S. Ghosh Department of Radiology, New Jersey Medical School–Rutgers School of Biomedical and Health Sciences, Rutgers University, Newark, NJ, USA S. Shah (*) : S. Ghosh Department of Medicine, New Jersey Medical School–Rutgers School of Biomedical and Health Sciences Rutgers, The State University of New Jersey, 185 South Orange Ave, Newark, NJ 07103, USA e-mail: [email protected]
75 % of barium enema cases, and 62.5 % of liver biopsy resulted in a payment to the plaintiff. Among all resolved cases, the median award was $30,000 for unrecognized foreign body retention, $100,000 for barium enema complications, and $400,000 for liver biopsy complication. Of all GI malpractice claims, failure to diagnose was the most prevalent. Among them, approximately three fourths of claims related to either the diagnosis of primary cancer or for detection of a pneumoperitoneum. Keywords Malpractice . Abdominal Imaging . Colonoscopy . Cancer . Pneumoperitoneum
Introduction The gastrointestinal system (GI), consisting of both hollow and solid organs, has long been an active area in which radiologists’ expertise has been deployed, both for the recognition of disease and increasingly for the instigation of treatment. Over the past 40 years, conventional radiologic studies, especially those of the GI tract, have gained technical incisiveness. Moreover, continual improvements in crosssectional modalities, i.e., US, CT, and MR as well as advances in isotopic examinations and interventional procedures have together broadened our capabilities, enabling us to find and treat diseases with increased facility and sophistication. Yet, inevitably as a result of our expanded armamentarium, despite the expectations that abnormalities will be recognized even when subtle that the assignment of specific diagnosis will be correct and that the techniques at our disposal will be definitive, errors have continued to occur either from omission or commission. Moreover, it will be likewise presumed that prompt communication will be made to both patients and referrers of the radiologist’s finding and that the proper sequence of tests will
Emerg Radiol
be recommended. Furthermore, because patients with acute gastrointestinal abnormalities are likely to be first seen in an emergency setting, emergency room (ER) radiologists are apt to be placed at risk for a misinterpretation of abdominal conditions as revealed on imaging studies. Thus, an evaluation of the frequency and characteristics of malpractice actions initiated against radiologists practicing gastroenterological imaging will be an anticipated concomitant of the work in this subspecialty. Recently, we have been afforded the opportunity to examine a large data set, encompassing the career long practices of 8,407 radiologists. We have recently reported this information, disaggregated by body system—chest, breast, bone, and gastrointestinal—but with no further analysis within each system [1, 2]. In this report, we extend the analysis to the specifics of GI malpractice cases, categorizing them by cause and location by organ as well as by outcome for or against the defendant radiologist and by the amount of the award when the decision was rendered in favor of the plaintiff.
all malpractice cases including date of initiation, outcome of the case, statement of the primary allegation, and payment received if the judgment was rendered in favor of the plaintiff. All prospective and continuing enrolled radiologists must disclose the circumstances of all malpractice claims in which he or she had been named as a defendant. Each radiologist was required to list each initiated malpractice suits even if the claim was withdrawn at anytime before a judgment was rendered. Information in each case in which the defendant radiologist was deemed at fault came from the files of the National Practitioners Data Bank (NPDB). Generally, the narrative provided by the NPDB consisted of a few sentence summary listing the primary allegation but not the nature of the practice venue in which the radiologic interchange took place. Additionally, awards to the plaintiff from direct payment by the radiologist were revealed although such payments were not necessarily reported to the NPDB. One-call medical had approximately 8,450 radiologists in its network as of August 2010. Data was obtained from the May 2007 through the April 2010 cycle.
Materials and methods
Results
This investigation was approved by our institutional review board and is HIPPA compliant. Data were retrieved from the credentialing files of One-Call Medical, Inc., a preferred provider organization specializing in diagnostic imaging services for group health, worker’s compensation, and auto insurance companies. All enrollees in One Call Medical’s panel of image interpreters must be credentialed initially and then on a recurrent 3-year cycle. Information required for credentialing consisted of name, age, gender, state of residency, board certification status, and details of
Thirty-two percent of the enrolled radiologists were named as defendants in at least one malpractice suit. Of the 4,073 total claims, 346 (8.49 %) were related to the gastrointestinal system. The two most frequent primary allegations were failure to diagnose, 228 (65.9 %), and procedural complications, 59 (17.1 %) (Fig. 1). The 59 cases allocated by primary allegation to procedural complications consisted of a wide range of differing etiologies. Perforation of the colon unrecognized by barium enema was cited most often with 16 cases (27 %),
Fig. 1 Total causes of gastroenterology malpractice suits
Emerg Radiol Table 1 Failure to diagnose causes Causes
Number
Percentage
Primary Cancer Pneumoperitoneum Appendicitis Foreign body Barium enema Other Feeding Tube Obstruction Gall stones Hemorrhage Unknown Total
72 44 33 10 1 34 2 7 8 4 13 228
31.5 19.3 14.5 4.4 0.4 14.9 0.9 3.1 3.5 1.8 5.7 100
followed by complications of liver biopsy 13 cases (22 %), and abdominal drainage procedural errors 7 cases (12 %). The interventive procedures of PTC and ERCP contributed only four (6.8 %) and three (5.1 %) cases, respectively. Failure to identify retained foreign body in the immediate post-operative period totaled three cases (5 %). Only one case of procedural error was due to virtual colonoscopy. Among the conditions that were claimed to not have been diagnosed correctly, the three most common were cancer 72 (31.6 %), pneumoperitoneum 44 (19.3 %), and appendicitis 33 (14.5 %). Of the various types of malignancies, colon cancer was the most frequent, encompassing 44 cases (61 %) of the total, seven times more than each of the next two most common malignancies—cancer of the stomach and cancer of the liver (Table 1). Next in frequency among diagnostic errors was failure to recognize a pneumoperitoneum, representing 44 cases (19.6 %) followed by errors in the diagnosis of Fig. 2 Relationship of total number of suits to those settled in favor of plaintiff
appendicitis, which contributed 33 cases (14.5 %) (Fig. 2). Four percent of the total was attributed to errors in the recognition of a pre-existing foreign body while the incorrect diagnosis of intestinal obstruction encompassing both overcalls and undercalls compromised seven cases (3 %). Unknown and others together added up to 17 % of all labeled errors in diagnosis. All other causes encompassing negligence, peripheral role of the radiologists, failure to recommend further testing, failure to communicate with healthcare worker or patient, and contrast reaction each contributed less than 5 %. With respect to decisions made at settlement or verdict 47 (75 %) of claims involving primary cancer, 41 (73.2 %) of free air cases and 15 (62.5 %) in which appendicitis was the diagnosis resulted in payment to the plaintiff. The median payment for primary cancer was $200,000, for pneumoperitoneum $215,000, and appendicitis $60,000. Of the procedurally related claims, 78.6 % involved failure to recognize foreign body (Fig. 3). Of the procedurally related claims, the median award was $100,000 for barium enema complications and $400,000 for liver biopsy complication (Fig. 4).
Discussion The medical literature regarding the features and frequency of gastrointestinal-based malpractice suits against radiologists is meager. More attention has been directed to those organ systems, which have most often been the focus of a claim of misdiagnosis, especially of cases of alleged errors in the recognition of breast disease and osseous fractures. A comprehensive study of malpractice among radiologists in Chicago over a 20-year interval, which was published in 1995, provides a reference [3]. When compared to our data, it
Emerg Radiol Fig. 3 Three most common causes for errors in diagnosis
revealed a measure of overall constancy in the percentage in gastroenterology malpractice cases as a percentage of all cases. In the period from 1990–1994 among the claims of misdiagnosis, 9 out of 155 (5.9 %) involved the GI tract. Our data revealed that 8.4 % were focused to this organ system, and nearly two thirds of them were each a consequence of an alleged error in diagnosis (5.6 %). The marked prevalence of colon cancer as a malpractice focus is likely to continue. The relative commonness of this malignancy, the expectation that small lesions if removed are curative but if allowed to remain and grow could become lethal, raises the stakes for their detection by either optical or virtual colonoscopy. Large bowel cancers have nearly the ideal features for engendering a susceptibility to a malpractice claim. The disease is treatable, it often affects otherwise healthy middle-aged people, and it is detectable by imaging techniques advocated as sensitive and comprehensive. It is relevant to note as well that if virtual colonoscopy becomes relied upon more heavily as a screening test, the risk will increase to radiologists who perform this technique. On the other hand, the apparent rarity of existing cases related to the Fig. 4 Three most common causes of procedural complications
complications of virtual colonoscopy in our data set should be reassuring. 1) The relative frequency of malpractice suits for failure to recognize free air is a concern of practice by gastrointestinal radiologists, and it is particularly crucial in the emergency setting, inasmuch as often no one but the radiologist has the expertise to detect the signs of a small and/or subtle pneumoperitoneum and to differentiate it from an innocuous lucency that simulates it. For even tiny perforations, if not observed promptly, the consequences are often disastrous [4, 5]. Pneumoperitoneum is not an entity present exclusively in the elderly and can occur in younger individuals including those who are not debilitated. Thus, the cases are attractive to plaintiff lawyers because of the financial reward a judgment may presage. The best defense against such suits is to be aware of the possibility of error in the appropriate clinical scenario and know very well its manifold appearances, some of which while subtle are
Emerg Radiol
nevertheless definitive [5, 6]. Furthermore, an inadequate technique in the evaluation of free air upon the initial presentation to the hospital runs the chance of failure to recognize free air. If the patient is too ill to be assessed by both a supine and upright view, a subtle collection of extraintestinal air below the diaphragm will be missed. Also, for the recumbently confined patient, a single abdominal view will not encompass the entirety of the abdomen, especially the uppermost abdomen where free air is most apt to collect. Thus, the diagnosis may not be achieved. Most likely, failure to diagnose free air will be lessened by the widespread adoption of CT as the initial ER radiology test for abdominal pain. For sure, this is a more sensitive test, but at the same time, it imposes a radiation burden and can add additional cost. 1. Gastrointestinal malpractice suits frequency result in a judgment in favor of the plaintiff. 2. Pneumoperitoneum is a common but not preponderant focus of such suits. 3. The nature of the presentation of free air makes the emergency setting a likely site for the failure to recognize free air. 4. The advent of CT and its wide distribution in ER radiology departments may make the misdiagnosis of pneumoperitoneum less likely although the technique imposes additional cost and radiation burden.
Conflict of interest The authors declare that they have no conflict of interest. Financial disclosures None.
References 1. Whang JS, Baker SR, Patel R, Luk L, Castro A 3rd (2013) The causes of medical malpractice suits against radiologists in the United States. Radiology 266(2):548–554 2. Baker SR, Whang JS, Luk L, Clarkin KS, Castro A 3rd, Patel R (2013) The demography of medical malpractice suits against radiologists. Radiology 266(2):539–547 3. Berlin L, Berlin JW (1995) Malpractice and radiologists in Cook County, IL: trends in 20 years of litigation. AJR Am J Roentgenol 165(4):781–788 4. Bansal J, Kamal RJ, Rao J, Kankaria J, Agrawal NN (2012) Effectiveness of plain radiography in diagnosing hollow viscus perforation: study of $1,723 patients of perforation peritonitis 19:115–119. 5. Levine MS, Scheiner JD, Rubesin SE, Laufer I, Herlinger H (1991) Diagnosis of pneumoperitoneum on supine abdominal radiographs 156:731–735 6. Baker, Stephen R., and Kyunghee C. Cho. The abdominal plain film with correlative imaging. 2nd ed. Stamford, Conn., Appleton & Lange, 1999. Print.
ORIGINAL ARTICLE
Radiology medical malpractice suits in gastrointestinal radiology: prevalence, causes, and outcomes Stephen R. Baker & Shivam Shah & Shanchita Ghosh
Received: 16 January 2014 / Accepted: 29 August 2014 # American Society of Emergency Radiology 2014
Abstract The purpose of this study is to determine the prevalence, causes, and outcomes of GI malpractice suits in a survey of 8,401 radiologists. The malpractice histories of 8,401 radiologists from 47 states were evaluated from credentialing data of all radiologists participating in the network of One Call Medical Inc. Thirty-two percent of radiologists were defendants in at least one malpractice suit. Of the 4,073 total claims, 346 (8.49 %) were related to the gastrointestinal system. The most frequent primary allegations were failure to diagnose, 65.9 %, and procedural complications, 17.1 %. The commonest missed diagnoses were malignancy, 31.6 %; pneumoperitoneum, 19.3 %; and appendicitis, 14.5 %. Payment to the plaintiff occurred in 75.8 % of claims pertinent to cancer, 73.2 % for missed pneumoperitoneum, and 62.5 % related to appendicitis. Of cases in which a ruling was made in favor of the plaintiff, median payments for pneumoperitoneum was $215,000, for primary cancer $200,000, and for appendicitis $60,000. Among procedurally related errors resulting in judgment against a defending radiologist, 78.6 % of claims regarding retained foreign body, Advances in knowledge Malpractice claims against radiologists with respect to gastrointestinal diseases comprise 8.49 % of all radiology malpractice claims. Errors in diagnosis were the most frequent reason for a claim with failure to detect colon cancer and pneumoperitoneum the most common causes. Overall, more than 70 % of gastroenterology lawsuits against radiologists resulted in resulted in payments to the plaintiff. S. R. Baker : S. Ghosh Department of Radiology, New Jersey Medical School–Rutgers School of Biomedical and Health Sciences, Rutgers University, Newark, NJ, USA S. Shah (*) : S. Ghosh Department of Medicine, New Jersey Medical School–Rutgers School of Biomedical and Health Sciences Rutgers, The State University of New Jersey, 185 South Orange Ave, Newark, NJ 07103, USA e-mail: [email protected]
75 % of barium enema cases, and 62.5 % of liver biopsy resulted in a payment to the plaintiff. Among all resolved cases, the median award was $30,000 for unrecognized foreign body retention, $100,000 for barium enema complications, and $400,000 for liver biopsy complication. Of all GI malpractice claims, failure to diagnose was the most prevalent. Among them, approximately three fourths of claims related to either the diagnosis of primary cancer or for detection of a pneumoperitoneum. Keywords Malpractice . Abdominal Imaging . Colonoscopy . Cancer . Pneumoperitoneum
Introduction The gastrointestinal system (GI), consisting of both hollow and solid organs, has long been an active area in which radiologists’ expertise has been deployed, both for the recognition of disease and increasingly for the instigation of treatment. Over the past 40 years, conventional radiologic studies, especially those of the GI tract, have gained technical incisiveness. Moreover, continual improvements in crosssectional modalities, i.e., US, CT, and MR as well as advances in isotopic examinations and interventional procedures have together broadened our capabilities, enabling us to find and treat diseases with increased facility and sophistication. Yet, inevitably as a result of our expanded armamentarium, despite the expectations that abnormalities will be recognized even when subtle that the assignment of specific diagnosis will be correct and that the techniques at our disposal will be definitive, errors have continued to occur either from omission or commission. Moreover, it will be likewise presumed that prompt communication will be made to both patients and referrers of the radiologist’s finding and that the proper sequence of tests will
Emerg Radiol
be recommended. Furthermore, because patients with acute gastrointestinal abnormalities are likely to be first seen in an emergency setting, emergency room (ER) radiologists are apt to be placed at risk for a misinterpretation of abdominal conditions as revealed on imaging studies. Thus, an evaluation of the frequency and characteristics of malpractice actions initiated against radiologists practicing gastroenterological imaging will be an anticipated concomitant of the work in this subspecialty. Recently, we have been afforded the opportunity to examine a large data set, encompassing the career long practices of 8,407 radiologists. We have recently reported this information, disaggregated by body system—chest, breast, bone, and gastrointestinal—but with no further analysis within each system [1, 2]. In this report, we extend the analysis to the specifics of GI malpractice cases, categorizing them by cause and location by organ as well as by outcome for or against the defendant radiologist and by the amount of the award when the decision was rendered in favor of the plaintiff.
all malpractice cases including date of initiation, outcome of the case, statement of the primary allegation, and payment received if the judgment was rendered in favor of the plaintiff. All prospective and continuing enrolled radiologists must disclose the circumstances of all malpractice claims in which he or she had been named as a defendant. Each radiologist was required to list each initiated malpractice suits even if the claim was withdrawn at anytime before a judgment was rendered. Information in each case in which the defendant radiologist was deemed at fault came from the files of the National Practitioners Data Bank (NPDB). Generally, the narrative provided by the NPDB consisted of a few sentence summary listing the primary allegation but not the nature of the practice venue in which the radiologic interchange took place. Additionally, awards to the plaintiff from direct payment by the radiologist were revealed although such payments were not necessarily reported to the NPDB. One-call medical had approximately 8,450 radiologists in its network as of August 2010. Data was obtained from the May 2007 through the April 2010 cycle.
Materials and methods
Results
This investigation was approved by our institutional review board and is HIPPA compliant. Data were retrieved from the credentialing files of One-Call Medical, Inc., a preferred provider organization specializing in diagnostic imaging services for group health, worker’s compensation, and auto insurance companies. All enrollees in One Call Medical’s panel of image interpreters must be credentialed initially and then on a recurrent 3-year cycle. Information required for credentialing consisted of name, age, gender, state of residency, board certification status, and details of
Thirty-two percent of the enrolled radiologists were named as defendants in at least one malpractice suit. Of the 4,073 total claims, 346 (8.49 %) were related to the gastrointestinal system. The two most frequent primary allegations were failure to diagnose, 228 (65.9 %), and procedural complications, 59 (17.1 %) (Fig. 1). The 59 cases allocated by primary allegation to procedural complications consisted of a wide range of differing etiologies. Perforation of the colon unrecognized by barium enema was cited most often with 16 cases (27 %),
Fig. 1 Total causes of gastroenterology malpractice suits
Emerg Radiol Table 1 Failure to diagnose causes Causes
Number
Percentage
Primary Cancer Pneumoperitoneum Appendicitis Foreign body Barium enema Other Feeding Tube Obstruction Gall stones Hemorrhage Unknown Total
72 44 33 10 1 34 2 7 8 4 13 228
31.5 19.3 14.5 4.4 0.4 14.9 0.9 3.1 3.5 1.8 5.7 100
followed by complications of liver biopsy 13 cases (22 %), and abdominal drainage procedural errors 7 cases (12 %). The interventive procedures of PTC and ERCP contributed only four (6.8 %) and three (5.1 %) cases, respectively. Failure to identify retained foreign body in the immediate post-operative period totaled three cases (5 %). Only one case of procedural error was due to virtual colonoscopy. Among the conditions that were claimed to not have been diagnosed correctly, the three most common were cancer 72 (31.6 %), pneumoperitoneum 44 (19.3 %), and appendicitis 33 (14.5 %). Of the various types of malignancies, colon cancer was the most frequent, encompassing 44 cases (61 %) of the total, seven times more than each of the next two most common malignancies—cancer of the stomach and cancer of the liver (Table 1). Next in frequency among diagnostic errors was failure to recognize a pneumoperitoneum, representing 44 cases (19.6 %) followed by errors in the diagnosis of Fig. 2 Relationship of total number of suits to those settled in favor of plaintiff
appendicitis, which contributed 33 cases (14.5 %) (Fig. 2). Four percent of the total was attributed to errors in the recognition of a pre-existing foreign body while the incorrect diagnosis of intestinal obstruction encompassing both overcalls and undercalls compromised seven cases (3 %). Unknown and others together added up to 17 % of all labeled errors in diagnosis. All other causes encompassing negligence, peripheral role of the radiologists, failure to recommend further testing, failure to communicate with healthcare worker or patient, and contrast reaction each contributed less than 5 %. With respect to decisions made at settlement or verdict 47 (75 %) of claims involving primary cancer, 41 (73.2 %) of free air cases and 15 (62.5 %) in which appendicitis was the diagnosis resulted in payment to the plaintiff. The median payment for primary cancer was $200,000, for pneumoperitoneum $215,000, and appendicitis $60,000. Of the procedurally related claims, 78.6 % involved failure to recognize foreign body (Fig. 3). Of the procedurally related claims, the median award was $100,000 for barium enema complications and $400,000 for liver biopsy complication (Fig. 4).
Discussion The medical literature regarding the features and frequency of gastrointestinal-based malpractice suits against radiologists is meager. More attention has been directed to those organ systems, which have most often been the focus of a claim of misdiagnosis, especially of cases of alleged errors in the recognition of breast disease and osseous fractures. A comprehensive study of malpractice among radiologists in Chicago over a 20-year interval, which was published in 1995, provides a reference [3]. When compared to our data, it
Emerg Radiol Fig. 3 Three most common causes for errors in diagnosis
revealed a measure of overall constancy in the percentage in gastroenterology malpractice cases as a percentage of all cases. In the period from 1990–1994 among the claims of misdiagnosis, 9 out of 155 (5.9 %) involved the GI tract. Our data revealed that 8.4 % were focused to this organ system, and nearly two thirds of them were each a consequence of an alleged error in diagnosis (5.6 %). The marked prevalence of colon cancer as a malpractice focus is likely to continue. The relative commonness of this malignancy, the expectation that small lesions if removed are curative but if allowed to remain and grow could become lethal, raises the stakes for their detection by either optical or virtual colonoscopy. Large bowel cancers have nearly the ideal features for engendering a susceptibility to a malpractice claim. The disease is treatable, it often affects otherwise healthy middle-aged people, and it is detectable by imaging techniques advocated as sensitive and comprehensive. It is relevant to note as well that if virtual colonoscopy becomes relied upon more heavily as a screening test, the risk will increase to radiologists who perform this technique. On the other hand, the apparent rarity of existing cases related to the Fig. 4 Three most common causes of procedural complications
complications of virtual colonoscopy in our data set should be reassuring. 1) The relative frequency of malpractice suits for failure to recognize free air is a concern of practice by gastrointestinal radiologists, and it is particularly crucial in the emergency setting, inasmuch as often no one but the radiologist has the expertise to detect the signs of a small and/or subtle pneumoperitoneum and to differentiate it from an innocuous lucency that simulates it. For even tiny perforations, if not observed promptly, the consequences are often disastrous [4, 5]. Pneumoperitoneum is not an entity present exclusively in the elderly and can occur in younger individuals including those who are not debilitated. Thus, the cases are attractive to plaintiff lawyers because of the financial reward a judgment may presage. The best defense against such suits is to be aware of the possibility of error in the appropriate clinical scenario and know very well its manifold appearances, some of which while subtle are
Emerg Radiol
nevertheless definitive [5, 6]. Furthermore, an inadequate technique in the evaluation of free air upon the initial presentation to the hospital runs the chance of failure to recognize free air. If the patient is too ill to be assessed by both a supine and upright view, a subtle collection of extraintestinal air below the diaphragm will be missed. Also, for the recumbently confined patient, a single abdominal view will not encompass the entirety of the abdomen, especially the uppermost abdomen where free air is most apt to collect. Thus, the diagnosis may not be achieved. Most likely, failure to diagnose free air will be lessened by the widespread adoption of CT as the initial ER radiology test for abdominal pain. For sure, this is a more sensitive test, but at the same time, it imposes a radiation burden and can add additional cost. 1. Gastrointestinal malpractice suits frequency result in a judgment in favor of the plaintiff. 2. Pneumoperitoneum is a common but not preponderant focus of such suits. 3. The nature of the presentation of free air makes the emergency setting a likely site for the failure to recognize free air. 4. The advent of CT and its wide distribution in ER radiology departments may make the misdiagnosis of pneumoperitoneum less likely although the technique imposes additional cost and radiation burden.
Conflict of interest The authors declare that they have no conflict of interest. Financial disclosures None.
References 1. Whang JS, Baker SR, Patel R, Luk L, Castro A 3rd (2013) The causes of medical malpractice suits against radiologists in the United States. Radiology 266(2):548–554 2. Baker SR, Whang JS, Luk L, Clarkin KS, Castro A 3rd, Patel R (2013) The demography of medical malpractice suits against radiologists. Radiology 266(2):539–547 3. Berlin L, Berlin JW (1995) Malpractice and radiologists in Cook County, IL: trends in 20 years of litigation. AJR Am J Roentgenol 165(4):781–788 4. Bansal J, Kamal RJ, Rao J, Kankaria J, Agrawal NN (2012) Effectiveness of plain radiography in diagnosing hollow viscus perforation: study of $1,723 patients of perforation peritonitis 19:115–119. 5. Levine MS, Scheiner JD, Rubesin SE, Laufer I, Herlinger H (1991) Diagnosis of pneumoperitoneum on supine abdominal radiographs 156:731–735 6. Baker, Stephen R., and Kyunghee C. Cho. The abdominal plain film with correlative imaging. 2nd ed. Stamford, Conn., Appleton & Lange, 1999. Print.
