Initial browse

Figure 1 shows the process and protocols used to establish the results are presented in a flow chart. It was conducted on Google and discover University of Botswana search engine using “errors”, “discrepancies”, “ultrasound reports”, “sonographer”, “malpractice”, “inevitable” “negligence”, and “radiology’’ as keywords. Initially, grey literature and journals that were obtained were vital in providing a general overview of the topic and potential literature search keywords that were later used in the systematic literature search.

A systematic review of studies published between 2010 and 2020 accessed on Science Direct, Web of Science, Medical Literature Analysis and Retrieval System Online (MEDLINE), PubMed and Google Scholar was conducted. The study retrospectively looked into previous studies and data was collected through in-depth thematic analysis of literature. The use of various databases and relevant academic databases was done in order to ensure that the results obtained are valid and reliable. The literature search keywords were linked accordingly with Boolean operators and they were “errors”, “discrepancies”, “sonographer”, “malpractice”, “inevitable” “radiology” and “negligence”.

To ensure that articles retrieved were robust and up to date only peer reviewed articles published within the last two decades but because of untenable number these were further filtered to those for the decade qualified for inclusion. These articles were then appraised using the checklist which shows the Critical appraisal tool program that were informed by literature [7] . This was a mechanism to ensure that they are unbiased with good external validity such that the conclusion drawn herein is reliable and applicable in practice the following table depicts the literature search strategy ( Table 1 ).

The literature search retrieved 947 articles in total. Abstracts of retrieved articles were assessed to exclude articles with topics that do not address the aim of this review. Then duplicate copies across the databases were removed. Only 56 and 47 articles were left for further inclusion consideration after the first and second screening steps, respectively. The 47 remaining articles were screened for relevance in addressing the research questions by evaluation of their full text, and 9 articles were removed for the reason as stated in the Prisma flow diagram ( Figure 2 ).

The final 38 studies were used to tabulate a literature review table ( Table 2 ).

The CASP results are attached to the document.

This study employed topic synthesis and fundamental frequency statistics to extract qualitative and quantitative trends from the literature. First, a detailed full-text analysis was performed on the 38 papers selected after screening to detect recurring themes, expressions, and interpretations connected to sonographic errors, their classifications, contributory variables, and legal implications. Secondly, the data gathered was thematically synthesised by assigning a correct theme to the data as well as grouping the supporting data under the most relevant theme as possible. This method allowed the data to provide interpretive insights into the institutional, perceptual, and procedural causes of reporting disparities beyond content aggregation [8] . Meanwhile, Microsoft Excel was utilised to calculate frequency statistics that quantified the prevalence of the discovered mistake types and causes according to the literature. Each theme was matched to numerical counts to enable statistical tabulation of patterns such scholars discovering system-related causes or under-reading errors [9] .

Finally, to simplify reading and cross-referencing, percentages were displayed in tables. This comprehensive analytical technique supported evidence-based conclusions about sonographer responsibility and training limitations while thoroughly investigating qualitative insights and stressing diagnostic mistake frequencies and patterns.

To assure academic integrity, data accuracy, and indirect participant dignity in the evaluated literature, this study followed strict ethical standards. The research used secondary data review, however ethical clearance was obtained to conform with university and international human participant data research requirements. The University of Botswana ethical review committee approved the research under its non-human subject review protocol. Analysing published study data without interacting with participants preserved privacy and confidentiality. None of the data sources contained patient information, and informed permission methods necessitate anonymisation and de-identification [10] . Due diligence was done to verify no articles breached copyright or used modified datasets. Use of PubMed, MEDLINE, and ScienceDirect reduced bias and fraudulent studies [11] . The analysis followed jurisdictional guidelines for litigation records and practitioner conduct from tribunal websites and regulatory authorities [12] .

Study bias was reduced using multiple ways. A transparent and repeatable Boolean operator literature search protocol across five major academic databases, including PubMed and Web of Science, minimised selection bias [8] . The search was limited to peer-reviewed papers published between 2010 and 2020 to balance recency, depth, and methodological consistency [13] . The review chose literature on error origins and sonographer neglect with conflicting findings to prevent confirmation bias [3] . After independent data extraction and thematic coding, two researchers conducted a consensus review to increase inter-rater reliability. To ensure quality, only peer-reviewed studies were included for final synthesis after grey literature was explored to identify themes and gaps [14] . These methods made the study legitimate and assured that its findings reflected ultrasonography inaccuracy and professional accountability scholarship.

The results shown in Table 3 above were gathered from 38 publications and the results were translated to smoothed percentages. The results on the common types of errors revealed that; 2 out of the 38 articles (5%) advocated for complacency error; 13% for faulty reasoning error; 11% for lack of knowledge error; 18% for under-reading (missed finding) error; 5% for poor communication error; 8% for technique error; 11% for poor examination error; 8% for history error; 11% for location error; 11% for satisfaction of search error; 5% for complication error; and 11% for satisfaction of report error. In this regard the modal result was under-reading or missed finding error with the highest frequency of 7 out of 38 articles while the median result was lack of knowledge error, technique error, and satisfaction of report error as vouched by 4 out of 38 articles reviewed hence the central tendency was that sonographers tend to make under-reading or missed finding errors in line with the modal result. Notably, in these results the total percent exceed 100% because some articles vouched for more than one type of error. There was some modification to the common types of errors by some scholars like [15] classifying the errors into two broad categories as perceptual errors (missed abnormality) and cognitive errors (wrong interpretation of abnormality).

The findings on the various causes of errors by Sonographers showed that the scholars had almost similar views although there were some modifications in categorising some of the causes of errors. The causes of errors by sonographers were organised into themes as shown in Table 3 .

Table 4 shows results obtained from 38 articles reviewed on the various causes of errors. The errors were attributed to various causes or a combination of causes as follows: 8% (3 out of 38) to inadequacy of clinical information; 5% to poor imaging technique; 11% to excessive workload; 8% to observation or interpretive errors; 5% to ambiguity of reports; 3% to medication management; 8% to poor communication; 8% to lack of resources; 3% to culture of the institution; 5% to technology; 11% to sonographer bias; 11% to poor working conditions; 5% to inexperienced staff; and 21% to the system. Inadequate clinical information included lack of patient history and absence patient’s previous report to compare with the current. An outline in the reviewed scholarly reports showed that a relevant clinical history of a patient increases accuracy of various interpretations by sonographers (8%). It was also noted that sonographers may choose a wrong imaging technique (5%), poorly set equipment (5%) and/or make wrong diagnosis such as under-readings and false positives (5%). Suggestions that modern ultrasound machines are preloaded with pre-set parameters for different body organs depending on the clinical presentation or the disease under study were recommended (8%).

It was reported that excess workload and long working hours resulted in fatigue (mental and visual) and failure to concentrate hence wrong judgments (11%). Furthermore, ambiguity/complex reporting system resulted in omissions such as inadequately labeled images (5%). Medication management as a contributor to errors resulting from poor communication between referring physicians and clinicians on medications offered to the patient as well as wrong dose of IV fluids by sonographers (3%). It was also noted that, poor communication during handovers between shifts also contributed to diagnostic errors (8%). Similarly, poor handover of patients from clinicians and physicians hence the sonographer lacked adequate information about the patient leading to wrong procedure, wrong patients, wrong side, and wrong site (8%). In addition to that, evidence showed that lack of resources was also a major cause of errors (8%); including understaffing of sonographers (use of inexperienced sonographers and low incomers) (5%), inadequate equipment and other supplies (5%). It was also noted that a culture of blame has induced fear on sonographers hence many errors not recorded and corrected (3%). Furthermore, 5% of the scholars attributed the cause of errors to technology but some of these scholars argued that most of the technological errors are due to lack of technical knowledge and training on operating the equipment. About 11% of the articles reviewed showed that sonographer bias was also a significant cause of diagnostic errors including cognitive bias, anchoring bias, outcome bias, zebra treat bias, premature closure bias, and confirmation bias.

About 4 out of 38 (11%) scholars reviewed also vouched that, diagnostic errors are due to poor working conditions including poor lighting, long working shifts, busy working environment, all these affected sonographers’ concentration, observations, and final judgment. Moreover, 5% of the scholars reviewed revealed that there was widespread use of inexperienced sonographers due to staff shortages since sonographers are a scarce skill in many countries. A large proportion of the articles (21%) attributed most of the errors by sonographers to the system of the institution including its poor policies and procedures, poor communication and reporting system, poor and ageing equipment, poor working conditions, and poor recruiting system. However, the results revealed that some previous studies have identified two broad categories of the causes of diagnostic errors as the human factors and system factors. It was also further revealed that errors of perception are a result of physiological processes and not necessarily by negligence or biasness of Sonographers in what some scholars referred to as unavoidable hazard of “human condition” . The study also revealed that the errors made by sonographers might lead to death of patients. At times sonographers face litigation for their actions from the patients or their families; malpractice lawsuits were on the rise with the majority of the suits being on missed diagnosis by Radiologists including Sonographers; the first ultrasound suit was in 1982 for, for CT was in 1982 and for MRI was in 1987 .

states that “The legal basis for negligence involves a breach of the standard of care, which is usually defined as being the use of the same degree of knowledge, skill and ability as an ordinary careful physician would exercise under similar circumstances”. It is evident that many legal judgments exonerated physicians including sonographers by stating that “physicians including Doctors and Sonographers cannot be required to be perfect and cannot be expected to guarantee a good result to patients” . [18] further elaborates that “Negligence occurs not when there is merely an error, but when the degree of error exceeds an acceptable standard”. However, in contrast to negligence, perfection is defined by The Devil’s Dictionary as “An imaginary state or quality distinguished from the actual by an element known as excellence, an attribute of the critic” [19] . The scholars reviewed only showed few cases of negligence that is only 17% of the articles, however it takes effort for sonographers to avoid errors as much as they can to avoid been sued.

The findings for this section were put into the following themes: well-structured reporting system; induction on all new equipment; policies and procedures; clear communication procedures/structure; medication management knowledge; collaborative team approach; culture of quality and safety; sophisticated IT equipment; and adequate resources for sonographers. These were derived from 16 scholars reviewed. All the scholars reviewed vouched that a well-structured reporting system such as use of incidents reports to allow reporting of all the errors including near misses by both Sonographers and patients or their families. About 30% of the scholars including [16] agreed that patients or their families must report perceived errors and unsafe practices by Sonographers. It was also revealed (85% of the scholars) that, Sonographers must be given adequate training and induction on operating and interpreting results on all new equipment to reduce errors relating to equipment setting and misinterpreting results in addition to undergoing continuous professional development. Various scholars (20%) and other medical institutions supported the use of Failure Modes and Effects Analysis (FMEA) protocol before introducing new procedures or equipment in order to reduce errors. A considerable portion of scholars (25%) showed that clear policies and procedures for Sonographers and the department at large helps in reducing errors including reporting, accessing patient clinical information policies and procedures such as handover between shifts such as Situation-Background-Assessment-Recommendations (SBAR), communication, medication administration, standard procedures for the various tasks such as checklists, and giving Sonographers access to clinical data and portals for referring physicians. Furthermore, 30% of scholars studied showed that clear communication is key in reducing errors by sonographers, communication about patient history, patient medications, key diagnosis, and clearly labelled images. Other scholars (15%) argued that sonographers must have medication management knowledge to avoid overdosing and other medication related errors; this includes understanding the five “rights” of medication administration; right medication; right patient; right dose; right time; and right route of administration.