Value of radiograph audit in an accident service department

doi:10.1016/0020-1383(92)90126-D

Injury

Volume 23, Issue 1, 1992, Pages 47-50

https://doi.org/10.1016/0020-1383(92)90126-D Get rights and content

Abstract

In our accident service department all trauma radiographs are reported acutely and those misinterpreted by the casually officers are presented at the daily clinicoradiological conference. We have reviewed this practice over a 6-month period.

From over 25000 patients attending the accident service, 16 246 radiographs were requested and reported. Of these, 456 (2.8 per cent) were considered to have been potentially misinterpreted. The errors included 167 (1 per cent) missed fractures, 55 (0.3 per cent) suspected fractures and 72 (0.4 per cent) false-positive diagnoses of fracture. Subsequently, 114 (0.7 per cent) patients required recall for treatment or further imaging. Incorrect diagnoses were seen most frequently in the more commonly injured anatomical sites — the ankle, wrist, foot, elbow and hand. However, the incidence of misinterpretation was highest in examination of the fingers, especially in children.

We believe that these low figures are principally the result of involving both orthopaedic surgeons and radiologists at the formal daily conference. We regard our system of audit as beneficial to patients' care and anticipate reduced litigation which may offset the increased cost of audit.

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Cited by (39)

After-hour trauma-radiograph interpretation in the emergency centre of a District Hospital
2022, African Journal of Emergency Medicine
Citation Excerpt :
The morbidity and mortality associated with missed fractures are well documented [7–10]. The accuracy of trauma radiographs reported by junior doctors has been extensively researched in the last half century [4,11–23]. Previous studies have largely been performed in well-resourced environments and have included all levels of healthcare facilities.
Plain radiographs remain a first-line trauma investigation. Most trauma radiographs worldwide are reported by junior doctors. This study assesses the accuracy of after-hour acute trauma radiograph reporting by emergency centre (EC) doctors in an African district hospital.
An institutional review board approved retrospective descriptive study over two consecutive weekends in February 2020. The radiologist report on the admission radiographs of adult trauma patients was compared with the initial EC interpretation. The accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for EC interpretation were calculated with 95% confidence intervals (95%CI). The association between reporting accuracy and anatomical region, mechanism of injury, time of investigation, and the number of abnormalities per radiograph was assessed.
140 radiographs were included, of which 49 (35%) were abnormal. EC doctors recorded (95%CI) 77% (69-84%) accuracy, 38% (25-54%) sensitivity, 97% (91-99%) specificity, 86% (65-95%) PPV and 76% (71-80%) NPV. Performance was associated with the anatomical region (p=0.02), mechanism of injury (p=<0.01) time of day (p=0.04) and the number of abnormalities on the film (p=<0.01). The highest sensitivity was achieved in reports of the appendicular skeleton (42%) and in the setting of simple blunt trauma (62%). Overall accuracy was in line with the range (44%-99%) reported in the international literature.
Accurate reporting of acute trauma radiographs is challenging. Key factors impact performance. Further training of junior doctors in this area of clinical practice is recommended. Future work should focus on assessing the impact of such training on reporting performance.
The accuracy of paediatric limb radiograph interpretation by nurse practitioners in a single centre
2019, International Emergency Nursing
Citation Excerpt :
Paediatric radiographs can be challenging to interpret due to the presence of growth plates in skeletally immature children, which could lead NPs to misidentify them as fractures on an otherwise normal radiograph – it is conceivable that this contributed to the high number of false positive results [13]. Thomas et al. [22] reported that finger radiographs – particularly in children – had the highest rate of misinterpretations, closely followed by the ankle, wrist, foot, elbow and hand. Moreover, Deakin et al. [6] agree that diagnostic errors occur the highest in the extremities, with feet being the first, followed by knee, elbow, hand, wrist, hip and ankle.
Nurse practitioners (NP) are an integral part of the urgent and emergency care workforce in the United Kingdom providing safe and effective care. Despite this, there is limited research assessing the ability of NPs to correctly interpret isolated paediatric limb injury radiographs in the urgent and emergency care environment.
The aim of this study was to compare the accuracy in interpreting isolated paediatric limb radiographs between NPs and consultant radiologists.
A nurse-led urgent care centre (UCC) in central London, United Kingdom.
296 paediatric patients with isolated limb injuries who had a radiograph requested and interpreted by an NP.
Thirteen NPs (adult registered) with various backgrounds and qualifications participated in this prospective, single-centre healthcare analysis. Review of all clinical presentations at the UCC over a 3-month period (September–November 2017) identified 296 paediatric patients (aged 2–15) who received a peripheral limb radiograph. Clinical records for each patient were analysed to document demographics, mechanism of injury, NP examination findings, radiographic interpretation and formal radiologist report. NP interpretation of each radiograph was classified as definite fracture, possible fracture or no fracture. This was compared to the final radiologist report (considered the gold standard) to calculate the sensitivity and specificity of NP radiograph interpretation.
NPs reported a total of 94 radiographs (32%) as definite fracture, 176 (59%) as no fracture and 26 (9%) as possible fracture, as compared to radiologists at 71 (24%), 218 (74%) and 7 (2%). A total of 242 (82%) of radiographs were correctly identified by NPs, while 54 (18%) were incorrectly interpreted. The sensitivity of the NP limb radiographic interpretation was 92%, with a specificity of 78%.
The findings validate the clinical and diagnostic skills of NPs in the interpretation of isolated paediatric limb radiographs.
The accuracy of adult limb radiograph interpretation by emergency nurse practitioners: A prospective comparative study
2014, International Journal of Nursing Studies
Citation Excerpt :
It appears that flagging these radiographs as “possible” fractures was appropriate in the majority of cases by all three clinician groups and demonstrates the limitations of a plain radiograph. Thomas et al. (1992) reported that the foot, wrist, ankle and hand were the most common anatomical sites for misdiagnosis. A possible explanation for the difference in results is the length of specialist clinician experience.
One of the extensions to practice for the emergency nurse practitioner role is to appropriately order and interpret radiographs in the emergency department.
The aim of the study was to compare the accuracy in interpreting isolated adult limb radiographs between emergency nurse practitioners and emergency physicians.
A prospective comparative study was undertaken.
Emergency department in a large metropolitan hospital.
200 adult patients with isolated limb injuries were consented.
Six emergency nurse practitioners and ten emergency physicians participated. One emergency physician and emergency nurse practitioner independently clinically assessed each patient, determined the need for radiograph and separately recorded their interpretation of the radiograph as either definite fracture, no fracture or possible fracture. A single consultant radiologist reviewed each radiograph and their interpretation was seen as the gold standard. The sensitivity and specificity of emergency physicians and emergency nurse practitioners were calculated. To measure the level of agreement between the two-clinician groups, the weighted Kappa statistic was used.
The sensitivity for the emergency nurse practitioners was 91% and 88% for the emergency physicians. The specificity for the emergency nurse practitioners was 85% and for the emergency physicians 91%. The weighted Kappa on the presence of a fracture between the emergency nurse practitioners and emergency physicians was 0.83.
This study validates the clinical and diagnostic skills of emergency nurse practitioners assessed in the interpretation of isolated adult limb injury radiographs.
Accuracy of radiographic readings in the emergency department
2011, American Journal of Emergency Medicine
A review of radiology discrepancies of emergency department (ED) radiograph interpretations was undertaken to examine the types of error made by emergency physicians (EPs).
An ED quality assurance database containing all radiology discrepancies between the EP and radiology from June 1996 to May 2005 was reviewed. The discrepancies were categorized as bone, chest (CXR), and abdomen (AXR) radiographs and examined to identify abnormalities missed by EPs.
During the study period, the ED ordered approximately 151 693 radiographs. Of the total, 4605 studies were identified by radiology as having a total of 5308 abnormalities discordant from the EP interpretation. Three hundred fifty-nine of these abnormalities were not confirmed by the radiologist (false positive). The remainder of the discordant studies represented abnormalities identified by the radiologist and missed by the EP (false negatives). Of these false-negative studies, 1954 bone radiographs (2.4% of bone x-rays ordered) had missed findings with 2050 abnormalities; the most common missed findings were fractures and dislocations. Of the 220 AXRs (3.7% of AXRs ordered) with missed findings, 240 abnormalities were missed; the most common of these was bowel obstruction. Of the 2431 CXRs (3.8% of CXRs ordered), 2659 abnormalities were missed; the most common were air-space disease and pulmonary nodules. The rate of discrepancies potentially needing emergent change in management based solely on a radiographic discrepancy was 85 of 151 693 x-rays (0.056%).
Approximately 3% of radiographs interpreted by EPs are subsequently given a discrepant interpretation by the radiology attending. The most commonly missed findings included fractures, dislocations, air-space disease, and pulmonary nodules. Continuing education should focus on these areas to attempt to further reduce this error rate.
Radiographer emergency department hot reporting: An assessment of service quality and feasibility
2008, Radiography
Citation Excerpt :
The highest number of discrepancies was shown amongst paediatric cases. Again, this finding is in line with those of other studies7,30,31 and suggests that additional training may be necessary to support reporting of these cases or alternatively, the adoption of double reporting. However, the numbers in this study were relatively small and further evaluation of this finding is recommended.
Radiographer reporting has been implemented widely as cold reporting. This study aimed to compare hot and cold reports by the same radiographer to establish whether there was any significant difference in the diagnostic outcome.
Three experienced radiographers reported 1618 musculoskeletal trauma cases over a 3 month period. These cases were stratified for age (0–17 years; 18–50 years; 51 years+) and a random sample of 400 cases selected (95% confidence interval, 90% power) for delayed reporting. Both reports were independently compared by 2 experienced film readers.
Radiographs and notes on 391 (97.8%; n = 391/400) cases were located (age range 3 months to 97 years) for cold reporting. The diagnostic outcome of the reports was concordant in 357 cases (91.3%; n = 357/391) and discrepant in 34 cases (8.7%; n = 34/391). Logistic regression performed on age stratified discrepancies indicated that paediatric cases had increased odds of receiving discrepant reports (OR = 3.34; p = 0.005; 95% CI [1.44–7.74]). Hot and cold report agreement was high (κ = 0.87). McNemar's test demonstrated no significant difference in the report discrepancies (p = 0.189).
No significant difference was demonstrated between the diagnostic outcome of radiographer hot reports, issued whilst working within the trauma radiography department at time of patient attendance, and cold reports.
Missed and Delayed Diagnoses in the Emergency Department: A Study of Closed Malpractice Claims From 4 Liability Insurers
2007, Annals of Emergency Medicine
Citation Excerpt :
Cognitive factors contributed to almost every missed diagnosis, but they usually acted in concert with other types of factors, particularly supervision, handoffs, workload levels, and patient-related factors. Most research into diagnosis errors in the ED has been aimed at specific diagnoses, particularly myocardial infarctions, fractures, and infections.8,14-20,37-40 Studies have identified problems in diagnostic steps such as history taking, interpretation of ECGs and radiographs, and clinical decisionmaking.40,41
Diagnostic errors in the emergency department (ED) are an important patient safety concern, but little is known about their cause. We identify types and causes of missed or delayed diagnoses in the ED.
This is a review of 122 closed malpractice claims from 4 liability insurers in which patients had alleged a missed or delayed diagnosis in the ED. Trained physician reviewers examined the litigation files and the associated medical records to determine whether an adverse outcome because of a missed diagnosis had occurred, what breakdowns were involved in the missed diagnosis, and what factors contributed to it. Main outcome measures were missed diagnoses, process breakdowns, and contributing factors.
A total of 79 claims (65%) involved missed ED diagnoses that harmed patients. Forty-eight percent of these missed diagnoses were associated with serious harm, and 39% resulted in death. The leading breakdowns in the diagnostic process were failure to order an appropriate diagnostic test (58% of errors), failure to perform an adequate medical history or physical examination (42%), incorrect interpretation of a diagnostic test (37%), and failure to order an appropriate consultation (33%). The leading contributing factors to the missed diagnoses were cognitive factors (96%), patient-related factors (34%), lack of appropriate supervision (30%), inadequate handoffs (24%), and excessive workload (23%). The median numbers of process breakdowns and contributing factors per missed diagnosis were 2 and 3, respectively.
Missed diagnoses in the ED have a complex cause. They are typically the result of multiple breakdowns in the diagnostic process and several contributing factors.

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PaperValue of radiograph audit in an accident service department

Abstract

Injury

Clin. Radiol.

A review of cervical spine radiographs in casualty patients

Br. J. Radiol.

Reducing errors in the accident department: a simple method using radiographers

Br. Med. J.

Radiological interpretation in an accident and emergency department

Br. J. Clin. Pract.

An assessment of the clinical effects of reporting accident and emergency radiographs

Br. J. Radiol.

Paper
Value of radiograph audit in an accident service department