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Hello everyone.

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I'm Michael Bruno from Penn State,

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and I'm gonna be talking to you about errors in

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radiology practice.

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Few disclosures, uh, few books I've written.

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I get royalties, uh, from these I've made dozens of dollars,

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uh, and, uh, uh, most recently, error in Uncertainty

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and di Diagnostic Radiology.

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And some of what are gonna talk about is gonna be a part

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of the content of that book.

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And I come to you from beautiful

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downtown Hershey, Pennsylvania.

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This is the Hershey Medical Center.

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It was, uh, named after its founder, Milton s Hershey,

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who also had an orphanage.

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And he decided that, uh, his, uh, his plan model,

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plan community needed a medical school and a hospital in it.

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And that's, that's why I'm here in Hershey.

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We really do have a corner of chocolate in Cocoa Avenue.

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By the way, whole town smells like chocolate most days.

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It's delightful. So, uh,

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let's talk about radiologist mistakes.

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Uh, you know, who makes mistakes?

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How many mistakes are made, and,

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and do we have unrealistic expectations for perfection?

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One of my, uh, esteemed colleagues from a previous

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institution said to me, uh, with doubt,

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the slightest trace of irony.

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Um, I have MD after my name,

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and that means I don't make mistakes.

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Uh, well, um, she was wrong.

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But, uh, you know, mistakes are sort

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of the elephant in the room

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and how many legs of this elephant actually have, um,

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you know, they, they can certainly affect our,

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uh, self-image.

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And of course, we feel terrible because others may be harmed

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and suffer from our mistakes.

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And, you know, this is generally

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how we feel when we find out that we made a mistake.

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Uh, but, you know, mistakes are inevitable

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and that we all make them,

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and we have to deal with our mistakes at multiple levels,

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institutionally, departmentally,

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and at the indi individual level as well.

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Uh, we do systems-based interventions, uh,

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practice quality improvement.

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Uh, we try to detect errors and prevent harm.

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We use educational interventions to try to sort

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of learn our way out of, uh, uh, out of certain kinds

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of mistakes and reduce our error risk through, uh,

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increasing our knowledge base, uh, this cognitive

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and learning interventions.

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But ultimately, we, you know, we, we sometimes have to, uh,

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deal with having to disclose that we made an error,

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apologize for an error,

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and make restitution, uh, for an error.