title: [Diagnostic and organizational error in head injuries].
abstract: The study aimed at presenting a case of a diagnostic and organizational error involving lack of detection of foreign body presence in the soft tissues of the head. Head radiograms in two projections clearly demonstrated foreign bodies that resembled in shape flattened bullets, which could not have been missed upon evaluation of the X-rays. On the other hand, description of the radiograms entered by the attending physicians to the patient's medical record indicated an absence of traumatic injuries or foreign bodies. In the opinion of the authors, the case in question involved a diagnostic error: the doctors failed to detect the presence of foreign bodies in the head. The organizational error involved the failure of radiogram evaluation performed by a radiologist.
authors.affiliation: Z Katedry i Zakłtadu Medycyny Sadowej, Uniwersytetu Medycznego im. Karola Marcinkowskiego w Poznaniu. czaba@amp.edu.pl
authors.forename: Czesław
authors.initials: C
authors.lastname: Zaba
authors.forename: Zbigniew
authors.initials: Z
authors.lastname: Zaba
authors.forename: Paweł
authors.initials: P
authors.lastname: Swiderski
authors.forename: Dorota
authors.initials: D
authors.lastname: Lorkiewicz-Muszyíska
mesh_terms: D000328:Adult; D006259:Craniocerebral Trauma / Q000175:diagnosis / Q000000981:diagnostic imaging*; D003951:Diagnostic Errors; D005547:Foreign Bodies / Q000000981:diagnostic imaging*; D006257:Head / Q000000981:diagnostic imaging; D006801:Humans; D008297:Male; D011859:Radiography; D017695:Soft Tissue Injuries / Q000175:diagnosis / Q000000981:diagnostic imaging*; D014948:Wounds, Gunshot / Q000175:diagnosis / Q000000981:diagnostic imaging*