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Reducing errors made by emergency physicians in interpreting radiographs: longitudinal study

BMJ 2000; 320 doi: (Published 18 March 2000) Cite this as: BMJ 2000;320:737
  1. James A Espinosa (jim010{at}, medical directora,
  2. Thomas W Nolan, statisticianb
  1. a Department of Emergency Medicine, Overlook Hospital, Atlantic Health System, 99 Beauvoir Avenue, Summit, NJ 07902, USA
  2. b Associates in Process Improvement, 1110 Bonifant Street, Silver Spring, MD 20910, USA
  1. Correspondence to: J A Espinosa
  • Accepted 23 February 2000


Objectives: To reduce errors made in the interpretation of radiographs in an emergency department.

Design: Longitudinal study.

Setting: Hospital emergency department.

Interventions: All staff reviewed all clinically significant discrepancies at monthly meetings. A file of clinically significant errors was created; the file was used for teaching. Later a team redesigned the process. A system was developed for interpreting radiographs that would be followed regardless of the day of the week or time of day. All standard radiographs were brought directly to the emergency physician for immediate interpretation. Radiologists reviewed the films within 12 hours as a quality control measure, and if a significant misinterpretation was found patients were asked to return.

Main outcome measures: Reduction in number of clinically significant errors (such as missed fractures or foreign bodies) on radiographs read in the emergency department. Data on the error rate for radiologists and the effect of the recall procedure were not available so reliability modelling was used to assess the effect of these on overall safety.

Results: After the initial improvements the rate of false negative errors fell from 3% (95% confidence interval 2.8% to 3.2%) to 1.2% (1.03% to 1.37%). After the processes were redesigned it fell further to 0.3% (0.26% to 0.34%). Reliability modelling showed that the number of potential adverse effects per 1000 cases fell from 19 before the improvements to 3 afterwards and unmitigated adverse effects fell from 2.2/1000 before to 0.16/1000 afterwards, assuming 95% success in calling patients back.

Conclusion: Systems of radiograph interpretation that optimise the skills of all clinicians involved and contain reliable processes for mitigating errors can reduce error rates substantially.


  • Funding None

  • Competing interests None declared

  • website extra Additional information about reliability modelling appears on the BMJ's website

  • Accepted 23 February 2000
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