fig 3.

78-year-old woman with back pain 5 years after a mastectomy for breast cancer.

A and B, An emergency lumbosacral spine CT was performed to evaluate for L3 compression fracture. The initial interpretation by the on-call resident identified multilevel degenerative changes with a questionable lesion at L5 versus degenerative change. The next morning, the staff neuroradiologist noted destructive lesions on the right side of L4 (A, arrows) and the posterior aspect of L5 (B, arrows), consistent with metastases. This error in interpretation was given a grade 4 (should have been identified) by the panel. The patient had been sent home instead of being admitted for metastatic workup, so she was called back the next day; however, the 6-hour delay in diagnosis did not change her outcome.