498 Patient safety alert: Medical image manipulation as a safety hazard for wrong-site procedures

Abstract

While some medical images are manipulated for patient benefit- radiograph rotation to aid during surgery and visible image enhancement to demonstrate plastic surgical outcomes, others have been manipulated causing patient harm- inadvertent flipping of x-rays resulting in wrong- side brain surgery, and an absence of photographs has caused wrong-site surgery in dermatology. We surveyed our department staff as well as the landscape of basic medical imaging devices, software, practices and current standards to ascertain actual and potential errors. Office- generated photographs may be stored natively in an electronic medical record (EMR) or in a separate medical imaging system which in most cases may allow flipping of images. Patient generated smart phone photographs, e.g. submitted in surgical follow-up through an EMR patient portal, have been noted to be wrong -sided, likely through image editing software. Selfies, which take a mirror image are usually but not always auto- flipped. Accurate dermatologic photographs are key to preventing wrong-site procedures but there is a need for education of providers and patients on the vagaries of the multiple cameras and software. There is also a current lack of agreement on standards in dermatologic imaging which often rely on consumer-based image formats which may not allow for efficient presentation of salient image metadata, such as laterality and anatomy. Current Digital Imaging and Communication in Medicine (DICOM) standards, initially used by radiology, have been adopted for dermatology images by the US Department of Veterans Affairs and may allow leveraging of DICOM network and workflow, interoperability of images and metadata, and existing enterprise imaging infrastructure, and better compliance with required image retention and improved patient safety.