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

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

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