• Arch Med Sadowej Kryminol · Jul 2009

    Case Reports

    [Diagnostic and organizational error in head injuries].

    • Czesław Zaba, Zbigniew Zaba, Paweł Swiderski, and Dorota Lorkiewicz-Muszyíska.
    • Z Katedry i Zakłtadu Medycyny Sadowej, Uniwersytetu Medycznego im. Karola Marcinkowskiego w Poznaniu. czaba@amp.edu.pl
    • Arch Med Sadowej Kryminol. 2009 Jul 1; 59 (3): 259-62.

    AbstractThe 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.

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