An Experimental Investigation of the Relationship between AI-Human Workflow Design and Legal Liability for Radiologists: The Erroneous-Change Penalty and Omission Bias

Background: With growing impetus to integrate artificial intelligence (AI) tools into radiology, clinical practices must navigate workflow redesign. This carries implications for medical malpractice liability. Methods: We conducted an online vignette experiment with United States adults who acted as hypothetical jurors in a malpractice case involving a missed intracranial hemorrhage. Participants (n=2,347) were randomized to one of 22 conditions: a no-AI control and 21 conditions involving a hypothetical AI system. These twenty-one conditions varied by whether (1) a single-read or double-read workflow was used, (2) the radiologist's initial interpretation was documented, (3) the radiologist changed their interpretation after viewing AI output, (4) the AI detected the abnormality, and (5) the AI error rate--False Discovery Rate (FDR) or False Omission Rate (FOR--was provided to participants only, both participants and radiologist, or neither. The primary outcome was perceived liability, assessed by whether the radiologist met their duty of care. Findings: Perceived liability differed across conditions (p<0.0001). Double-read workflows (p<0.0001), documenting initial interpretations (p=0.0125), and providing participants with AI error rates, including the FDR (p=0.0038) or FOR (p=0.0035), reduced perceived liability. Liability was also lower when AI was incorrect (p<0.0001). Radiologists' awareness of AI error rates did not significantly impact liability. Notably, we observed an erroneous change penalty: the greatest liability occurred when radiologists initially identified an abnormality but later changed their interpretation to normal after seeing that AI identified the case as normal; conversely, perceived liability was lowest with documented, double-read workflows. Interpretation: Double-read workflows with documented initial interpretations and disclosure of AI error rates reduce perceived liability, though changing a correct initial interpretation increases it. Strategic workflow design is critical for successful AI implementation that can mitigate malpractice risk.