Mirror-image reversal of coronal computed tomography scans

Objectives/Hypothesis: Mirror-image reversal of coronal computed tomography (CT) scans can be a significant problem in patient care, potentially leading to wrong-sided surgery and malpractice suits. There is no literature describing the problem of mirror-image reversal of coronal CT scans. Generally, medical errors are not widely published: however, with the emphasis on reduction of errors in medicine, this topic should be openly discussed. Study Design: Retrospective review of patient care and an assessment of current methods. Methods: Two cases of mirror-image reversal of coronal CT scans were reviewed, and the authors found that each case represented a different type of error. In the first case, the error was recognized in the operating room. The second case resulted in wrong-sided surgery, and a lawsuit was filed. These two separate occurrences led to a review of the methods for determining right versus left side for orienting and labeling of CT scans. Orientation of coronal scans depends on whether the patient is prone or supine. Thus, technician input is required. If a labeling mistake is made, radiologists may not readily catch the mistake because of the symmetry of the head and neck anatomy. Results: A review of the markings on each scan should provide the otolaryngologist with enough information to determine whether the scan is mislabeled. Conclusion: The incidence of mislabeled coronal CT scans is unknown. This error can result in inappropriate patient care and lawsuits for wrong-sided surgery. Awareness of the potential problem and open discussion of interpretation and prevention are necessary.