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PAPERS: James A Espinosa and Thomas W Nolan Reducing errors made by emergency physicians in interpreting radiographs: longitudinal study BMJ 2000; 320: 737-740 [Abstract] [Full text]

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reducing errors of radiographic interpretation

Elizabeth Miller   (20 March 2000)

System works

Jonathan Aldridge   (10 April 2000)

Radiograph systems

Gavin D Perkins   (19 April 2000)

Emergency X-ray Studies

Kim Bullock   (9 May 2000)

radiographer input.

Nia Leake   (25 August 2001)

reducing errors of radiographic interpretation 20 March 2000
Elizabeth Miller, general practice London Send response to journal: Re: reducing errors of radiographic interpretation	Espinosa and Nolan have produced an excellent paper demonstrating audit and systems modelling in action. Nevertheless, a long time ago, when I was an A&E Registrar, we taught 'more fractures are missed by examining the Xray, than are missed by examining the patient.' There remains some truth in it, especially if the fracture is undisplaced or impacted. Yours Elizabeth Miller AKC, FRCSE, MRCGP
System works 10 April 2000
Jonathan Aldridge Send response to journal: Re: System works	EDITOR - In response to Espinosa et al. reducing errors made by emergency physicians in reporting radiographs1, we would like to concur with their sentiments and findings. In our institution (District general hospital Accident and Emergency department) we have operated an almost identical system for over 10 years, in accordance with British Association of Accident and Emergency guidelines.2 Key points being: the rapid return of all radiographs to the requesting physician; the reporting of the radiographs by Consultant radiologists within 24 hours; the recall of any patients with errors made in interpreting radiographs by telephone; and the use of any such radiographs as a teaching exercise for all staff. Difference in the systems include reporting of plain radiographs within 24 hours in our institution rather than 12 hours, but additional level of input in the marking of radiographs as 'abnormal' by radiographers. The utilisation of the experience of the radiographers adds another tear of safety to the system. The radiographer marks all 'abnormal' radiographs with a 'red dot'. This part of the system is audited on a regular basis (last audit: sensitivity 93%; specificity 97%). The effects of such a 'fail safe' system are several: patient satisfaction is subjectively better - knowledge that all radiographs are reported; few complaints over misinterpretation; and a culture of learning and co- operation amongst junior staff. Continuous audit data reveal a remarkably low rate of clinically significant misinterpretation: 0.64% of all plain radiographs (Range 0 - 1.4% per month, data from 90 consecutive months). This compares with false negative rate of 0.3% (0.265 to 0.34%) in the index study1. We feel that this is an excellent standard of systematic approach to what is an error prone activity, both reducing mistakes by A&E staff (often junior), increasing patient satisfaction and reducing long term patient morbidity and litigation. We feel that this is the type of systematic and safe approach eluded to in another article in the same journal by Barach et al.3 applied in a medical context. Jonathan Aldridge, SHO in Accident and Emergency Peter Freeland, Consultant in Accident and Emergency St John's Hospital at Howden, Howden Road West, Livingston. West Lothian EH54 References: 1 Espinosa J, Nolan T, Reducing errors made by emergency physicians in interpreting radiographs: longituinal study. BMJ 2000;320:737-744 2. British Association for Accident and Emergency Medicine, clinical services committee, X-Ray reporting for accident and emergency departments. 3. Barach P, Small S, Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ 2000;320:759-763
Radiograph systems 19 April 2000
Gavin D Perkins Send response to journal: Re: Radiograph systems	Editor - the paper by Espinosa and Nolans' [1] regarding their approach to reducing errors in radiograph interpretation re-emphasises the importance of training and developing systems for radiograph interpretation. Whilst this study was based in the emergency department we suggest the problem with interpretation of radiographs is more widespread and that this needs to be recognized particularly in the context of adopting to published guidelines or local protocols which rely on radiological interpretation. We recently undertook an audit on the management of spontaneous pneumothorax based on the British Thoracic Society guidelines [2] at our hospital which, similar to the findings of others [3], demonstrated poor adherance to the guidelines. Symptoms aside, as the guideline algorithms depend on an interpretation of the presenting chest radiograph, and in particular the pneumothorax size and presence of underlying lung disease, we decided to evaluate inter and intra-observer variablity of three non- consultant doctors at a junior, middle, and senior grade (all non- radiologists) who would be involved in an acute unselected medical take. 34 x-rays of patients with spontaneous pneumothorax were reviewed blind to the clinical context with test and retest at least two weeks apart and the level of inter and intra-observer agreement was measured using Cohen's weighted kappa statistic for ordinal data. Analysis suggested that there was a moderate to high level of inter-observer agreement in reporting the size of the pneumothorax (range 0.547-0.830) between doctors but a poor to moderate level in reporting the presence of underlying lung disease (0.147 - 0.672). Re-testing at two weeks found high levels of intra-observer agreement (0.672- 0.879) at junior and middle grade but only moderate levels of agreement at senior grade (0.55-0.600). Whilst it is possible, in part, to attribute the inter-observer variability to the experience of the reporter, the intra-observer variablity may suggest a failure in the system utilised for radiography interpretation. For consistency of reporting, and further correct deployment of clinical guidelines, we recommend continued attention is paid to education and systems for radiograph interpretation. Gavin D Perkins, Specialist Registrar Sunil Kumar, Senior House Officer Harmesh Moudgil, Consultant Department of Respiratory Medicine Princes Royal Hospital, Telford. TF6 6TF Conflict of interest:None [1] Espinosa JA, Nolan TW. Reducing errors made by emergency physisicans in interpreting radiographs: longitudinal study. BMJ 2000;7232:737-741 [2] Miller AC, Harvey AC. Guidelines for the management of spontaneous pneumothorax. BMJ 1993;307:114-6 [3] Soulsby T. British Thoracic Society guidelines for the management of spontaenous pneumothorax: do we comply with them and do they work ? J Accid Emerg Med 1998:17-21
Emergency X-ray Studies 9 May 2000
Kim Bullock Send response to journal: Re: Emergency X-ray Studies	The implementation of a system to reduce errors associated with interpreting emergency x-ray studies and patient recalls is critical, both in terms of optimum patient care as well as decreasing liability risk. The authors of the article "Reducing errors made by emergency physicians in interpreting radiographs: longitudinal study," BMJ, 2000 ;320:737, describes a collaborative oversight approach similar to what our hospital has done over the last six (6) years. Prior to instituting a standard where the radiographs were immediately reviewed by the emergency physician, with formal interpretive back-up within twelve (12) to twenty-four (24) hours, the clinically significant recall error rate was 4 percent. At that time (although the x-ray machine was located within the department) little discussion existed between the radiologist and the emergency physician concerning the clinical scenarios of patients who presented, or feedback in terms of missed radiographic findings. Most importantly, there was no effective quality assurance (QA) mechanism for the emergency physicians to learn and improve their interpretive skills. The system changes for emergency handling of x-rays included immediate review of all films by the emergency physician. This was followed by immediate over read by an assigned radiologist, whenever possible, according to the daily schedule. All films were required to be read within 12-24 hours with feedback on discrepancies to the emergency physician. A specific form was completed, which triggered a formal QA review and a presentation of significant errors, on a monthly basis. The patients were notified to return for immediate follow up and definitive treatment. Over the several years since this policy has been in place, the significant error rate reduced to less than 1 percent. This was due to the radiology written and verbal feedback. Trending error data has also allowed for specific formal radiology CME training or departmental reviews, as well as improved collegial interactions between the two (2) disciplines. There was also significant positive feedback from patient satisfaction surveys, in spite of the fact that a certain amount of inconvenience was created because of a return visit due to the physician's error. This was particularly important since there were several instances where the "missed" radiographic abnormality was considered critical and could have resulted in serious risk management and liability concern. The hospital has considered extending this same oversight procedure to include ultrasound and CT scan readings. Clearly this new approach to handling emergency radiographic interpretations has translated into multiple benefits, in addition to a cost saving associated with decreased return visits. This interdepartmental change at our community-based hospital has had a tremendous impact on improving service delivery to patients within a potential high risk error environment. Kim Bullock, M.D. Assistant Chair Emergency Department
radiographer input. 25 August 2001
Nia Leake, radiographer a+e,leicester Send response to journal: Re: radiographer input.	It would appear in this article that at no time did the authors compare the results with the rate of detection of abnormality amongst the radiographic staff.Surely, in a busy emergency environment ,the highly trained and experienced radiographers producing the films would be a junior doctors' first port of call if they were in any doubt about a film.Whilst we legally cannot report on a film,we can give a verbal opinion. We also operate a 'red dot system', and frequently have medical staff contacting us to ask why we have dotted a film and we are only to pleased to help. .