Applying the Updated Renfrew Error Classification and Osteopathic Principles to Radiology Interpretation: A Case-Based Approach

Philadelphia, PA

Background: Diagnostic errors in radiology can lead to delayed or incorrect diagnoses. The updated Renfrew error classification system (updated by Kim and Mansfield in 2014) is a commonly cited framework for classifying diagnostic errors in radiology. Osteopathic medicine principles, on the other hand, provide a more general framework that focuses on a whole-person, patient-centered approach to diagnosis and interpretation in medicine. This study examines three documented cases of diagnostic errors in radiology through the lens of both frameworks to propose strategies for error reduction.

Methods: Three radiology cases with documented errors were analyzed and classified according to the updated Renfrew error classification system. Each case was assessed for factors contributing to the errors with a focus on how application of osteopathic tenets and principles may mitigate these errors.

Results: The Renfrew errors identified in the four cases we reviewed include missed edge-of-image pathology, satisfaction of search, faulty, communication breakdown, and underreading.

Case one involved a pathological humeral fracture missed on a chest X-ray, likely due to distraction–satisfaction of search error–by a complete left hemithorax white-out with mediastinal shift. The fracture was also at the image’s edge. An osteopathic implementation of a holistic approach—integrating the patient’s malignancy history and using a standardized search pattern—may have prevented errors of satisfaction of search and missed edge-of-image pathology.

Case two involved a skull fracture on a scout image–which was overlooked. While scout images are primarily for positioning, they can still reveal pathology not captured in diagnostic images. A more osteopathic approach—systematically reviewing all images holistically and applying a standardized search pattern that includes all available images—could have prevented this edge-of-image pathology error.

Case three involved a missed diagnosis of slipped capital femoral epiphysis (SCFE), initially interpreted as normal in the emergency department. The abnormality was later identified after discharge, but due to a communication breakdown, the patient was lost to follow-up. Months later, the patient presented to his PCP with worsening pain and decreased mobility, and repeat imaging confirmed SCFE progression. This case illustrates the errors of underreading and communication breakdown, emphasizing the osteopathic tenet that structure and function are interrelated—disease progression led to impaired mobility and increased pain. Improved interdisciplinary and physician-patient communication, which aligns with the osteopathic principle of facilitating patient-centered care, could have mitigated disease progression and its impact on physical function.

Conclusion: Applying osteopathic principles to image interpretation may help reduce errors in radiology. Integrating patient history with imaging findings and systematically reviewing all aspects of the image, including areas at the periphery, can reduce errors classified by the Renfrew system. This approach highlights the application of the osteopathic tenet of the body as a unified system of body, mind, and spirit. Additionally, improving communication among physicians and with patients aligns with the osteopathic principle of patient-centered care, emphasizing the importance of collaboration and closed-loop communication. These strategies, grounded in osteopathic medicine, may enhance diagnostic accuracy and promote better patient care and outcomes.