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Howie AR, Gajera J, Ong D, Roberts M. After-hours radiology reporting in an Australian tertiary hospital: Factors influencing the rate of discrepancy for computed tomography reporting. J Med Imaging Radiat Oncol 2023; 67:13-19. [PMID: 35699391 DOI: 10.1111/1754-9485.13445] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 06/01/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Demand for after-hours radiology services across Australia has been rapidly increasing for many years. Public hospital radiology departments are generally staffed by trainees after hours, often 1-2 doctors. This study reviewed 1 year of after-hours data at a tertiary hospital in Sydney, to determine overall discrepancy rates and factors which influenced the rate of discrepancy after hours. Overall radiology and after-hours case volumes are increasing, and the goal was to ensure that our department practices are within safe limits at current staffing levels. METHODS After-hours computed tomography scan reports issued by registrars were reviewed over 1 year between 01 January 2019 and 01 January 2020. Data recorded included overall case numbers on each shift, discrepancy rates and rates of clinically significant discrepancy. Caseload was measured by equivalent ascribed reporting time as described by Pitman et al. (2018). RESULTS There were 10,886 cases reported after hours during the study period and 1,412 discrepancies (13% cases). Of these, 300 (3.7%) were clinically significant. Factors that increased the rate of significant discrepancy included shifts with caseloads greater than 3 h of equivalent consultant reporting time per 8-h shift and the radiology trainee's level of training. The frequency of discrepancy for trauma cases was similar to non-trauma after adjusting for study type; however, the frequency of significant discrepancy was higher. CONCLUSION In all instances, the rates of discrepancy and clinically significant discrepancy remained well within ranges previously described.
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Affiliation(s)
| | - Jay Gajera
- Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - David Ong
- Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Marian Roberts
- Royal North Shore Hospital, Sydney, New South Wales, Australia
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2
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Yang SJ, Lim HJ, Park SH, Choi SJ, Shim YS. Interpretation discrepancies of abdominal imaging by on-call radiology residents: Evaluation of risk factors. PLoS One 2022; 17:e0274313. [PMID: 36084145 PMCID: PMC9462765 DOI: 10.1371/journal.pone.0274313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 08/25/2022] [Indexed: 11/18/2022] Open
Abstract
The aim of this study was to determine the rate, important findings, and risk factors related to discrepancies between on-call residents’ and attending radiologists’ interpretations of abdominal examinations. We identified 1132 eligible patients with abdominal radiology findings that were preliminary interpreted by on-call residents between February 2016 and September 2019. The preliminary interpretations were compared with the final interpretations by abdominal attending radiologists, including clinical data. The preliminary interpretations were analyzed by three radiologists in consensus, who categorized the reports according to organs, important findings (i.e., active bleeding, bowel obstruction, organ ischemia or infarction, and organ rupture), clinical outcomes, and discrepancies with respect to final interpretations. Multiple logistic regression analysis was used to evaluate the risk factors for important discrepant findings. Of 1132 patients, the bowel (n = 567, 50.1%) was the most common organ interpreted by on-call residents, followed by gallbladder/bile duct/pancreas (n = 139, 12.3%) and liver (n = 116, 10.2%). Of 1132, 359 patients (31.7%) had disease with 379 important findings: active bleeding (n = 222), organ rupture (n = 77), bowel obstruction (n = 52), bowel ischemia (n = 24), and organ infarction (n = 4). Sixty-four patients (5.6%) showed discrepancies, and 30 (2.6%) showed 32 important discrepant findings comprising 14 active bleeding, 10 bowel obstructions, 6 organ ruptures, and 2 cases of bowel ischemia. Of the 64 discrepant patients, 33 underwent delayed surgery (n = 18, 28.1%) or interventional treatment (n = 15, 23.4%). In multivariable analysis, bowel obstruction (adjusted odds ratio, 2.52; p = 0.049) was an independent risk factor for determining discrepancy between preliminary and final interpretations. The rate of overall and important discrepancies between on-call residents’ and final interpretations was low. However, given that the bowel was the most frequently interpreted organ, bowel obstruction was identified as a risk factor for discrepant interpretations. The identified risk factor and findings may be useful for residents to minimize discrepancies.
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Affiliation(s)
- Su Jeong Yang
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, Namdong-gu, Incheon, Korea
| | - Hee Joong Lim
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, Namdong-gu, Incheon, Korea
| | - So Hyun Park
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, Namdong-gu, Incheon, Korea
- * E-mail:
| | - Seung Joon Choi
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, Namdong-gu, Incheon, Korea
| | - Young Sup Shim
- Department of Radiology, Gil Medical Center, Gachon University College of Medicine, Namdong-gu, Incheon, Korea
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3
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Salca D, Lersy F, Willaume T, Stoessel M, Lefèvre A, Ardellier FD, Nicolaï C, Nouri A, Baloglu S, Bierry G, Chammas A, Kremer S. Evaluation of neuroradiology emergency MRI interpretations: low discrepancy rates between on-call radiology residents' preliminary interpretations and neuroradiologists' final reports. Eur Radiol 2022; 32:7260-7269. [PMID: 35435441 DOI: 10.1007/s00330-022-08789-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 03/15/2022] [Accepted: 04/01/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To evaluate the performance of on-call radiology residents in interpreting alone brain and spine MRI studies performed after hours, to describe their mistakes, and to identify influencing factors that increased the occurrence of errors. METHODS A total of 328 MRI examinations performed during a 13-month period (from December 1, 2019, to January 1, 2021) were prospectively included. Discrepancies between the preliminary interpretation of on-call radiology residents and the final reports of attending neuroradiologists were noted and classified according to a three-level score: level 1 (perfect interpretation or minor correction), level 2 (important correction without immediate change in patient management), or level 3 (major correction with immediate change in patient management). Categorical data were compared using Fisher's exact test. RESULTS The overall discrepancy rate (level-2 and level-3 errors) was 16%; the rate of major discrepancies (only level-3 errors) was 5.5%. The major-discrepancy rate of second-year residents, when compared with that of senior residents, was significantly higher (p = 0.02). Almost all of the level-3 errors concerned cerebrovascular pathology. The most common level-2 errors involved undescribed aneurysms. We found no significant difference in the major-discrepancy rate regarding time since the beginning of the shift. CONCLUSIONS The great majority of examinations were correctly interpreted. The rate of major discrepancies in our study was comparable to the data in the literature, and there was no adverse clinical outcome. The level of residency has an effect on the rate of serious errors in residents' reports. KEY POINTS • The rate of major discrepancies between preliminary MRI interpretations by on-call radiology residents and final reports by attending neuroradiologists is low, and comparable to discrepancy rates reported for head CT interpretations. • The youngest residents made significantly more serious errors when compared to senior residents. • There was no adverse clinical outcome in patient morbidity as a result of an initial misdiagnosis.
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Affiliation(s)
- Diana Salca
- Hôpitaux Universitaires de Strasbourg, Service d'imagerie 2, Hôpital de Hautepierre, Strasbourg, France.
| | - François Lersy
- Hôpitaux Universitaires de Strasbourg, Service d'imagerie 2, Hôpital de Hautepierre, Strasbourg, France
| | - Thibault Willaume
- Hôpitaux Universitaires de Strasbourg, Service d'imagerie 2, Hôpital de Hautepierre, Strasbourg, France
| | - Marie Stoessel
- Hôpitaux Universitaires de Strasbourg, Service d'imagerie 2, Hôpital de Hautepierre, Strasbourg, France
| | - Agnieszka Lefèvre
- Hôpitaux Universitaires de Strasbourg, Service d'imagerie 2, Hôpital de Hautepierre, Strasbourg, France
| | - François-Daniel Ardellier
- Hôpitaux Universitaires de Strasbourg, Service d'imagerie 2, Hôpital de Hautepierre, Strasbourg, France
| | - Caroline Nicolaï
- Hôpitaux Universitaires de Strasbourg, Service d'imagerie 2, Hôpital de Hautepierre, Strasbourg, France
| | - Abtine Nouri
- Hôpitaux Universitaires de Strasbourg, Service d'imagerie 2, Hôpital de Hautepierre, Strasbourg, France
| | - Seyyid Baloglu
- Hôpitaux Universitaires de Strasbourg, Service d'imagerie 2, Hôpital de Hautepierre, Strasbourg, France
| | - Guillaume Bierry
- Hôpitaux Universitaires de Strasbourg, Service d'imagerie 2, Hôpital de Hautepierre, Strasbourg, France.,Engineering Science, Computer Science and Imaging Laboratory (ICube), Integrative Multimodal Imaging in Healthcare, UMR 7357, University of Strasbourg-CNRS, Strasbourg, France
| | - Agathe Chammas
- Hôpitaux Universitaires de Strasbourg, Service d'imagerie 2, Hôpital de Hautepierre, Strasbourg, France
| | - Stéphane Kremer
- Hôpitaux Universitaires de Strasbourg, Service d'imagerie 2, Hôpital de Hautepierre, Strasbourg, France.,Engineering Science, Computer Science and Imaging Laboratory (ICube), Integrative Multimodal Imaging in Healthcare, UMR 7357, University of Strasbourg-CNRS, Strasbourg, France
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Hussain B, Kannikeswaran N, Mathew R, Arora R. Evaluation of advanced practice provider related return visits to a pediatric emergency department and their outcomes. Am J Emerg Med 2021; 52:174-178. [PMID: 34942426 DOI: 10.1016/j.ajem.2021.11.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 11/22/2021] [Accepted: 11/29/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND While multiple studies have evaluated physician-related return visits (RVs) to a pediatric emergency department (PED) limited data exists for Advanced Practice Provider (APP)-related RVs, hence our study aimed to evaluate APP-related RVs and their outcomes in a PED. METHODS We conducted a retrospective review of 72-h RVs where clinical care was independently provided by an APP during the index visit from January 2018 to December 2019. We extracted patient demographics, index and return visits' characteristics and outcomes. Reasons for RVs were categorized as progression of illness, medication-related, callbacks and others. Index visits were assessed for any diagnostic errors; impact of which to the patient was classified as none, minor or major. RESULTS Our APP-related RV rate was 2.1% (653/30,328). 462 eligible RVs were included in the final analysis. Majority of RVs were for medical reasons (n = 442, 95.7%); lower acuity (Emergency Severity Index ≥3, n = 426, 92.2%); due to persistence/progression of illness (n = 403; 87.2%) with viral illness being the common diagnosis (n = 159; 34.4%). 12 (2.6%) RVs were secondary to callbacks (8 radiology callbacks; 4 false positive blood cultures). Diagnostic errors were noted in 14 (3%) encounters of which 3 resulted in a major impact; radiological (7 fractures) and ophthalmological (2 corneal abrasions and 2 foreign bodies) misses constituted the majority of these. CONCLUSIONS APP-related RVs for low acuity medical patients remain low and are associated with good outcomes. Diagnostic errors account for a minority of these RVs. Focused interventions targeting provider errors can further decrease these RVs.
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Affiliation(s)
- Batool Hussain
- Pediatric Emergency Medicine Fellow, Children's Hospital of Michigan, 3901 Beaubien Blvd, Detroit, MI 48201, United States of America.
| | - Nirupama Kannikeswaran
- Pediatrics and Emergency Medicine, Central Michigan University, Carman and Ann Adams Department of Pediatrics, Division of Emergency Medicine, Children's Hospital of Michigan, MI, United States of America.
| | - Reny Mathew
- Pediatric Resident, Children's Hospital of Michigan, MI, United States of America.
| | - Rajan Arora
- Pediatrics and Emergency Medicine, Central Michigan University, Carman and Ann Adams Department of Pediatrics, Division of Emergency Medicine, Children's Hospital of Michigan, MI, United States of America.
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Vendrell JF, Frandon J, Boussat B, Cotton F, Ferretti G, Sans N, Tasu JP, Beregi JP, Larbi A. Double Reading of Outsourced CT/MR Radiology Reports: Retrospective Analysis. J Patient Saf 2021; 17:e1267-e1271. [PMID: 30531236 DOI: 10.1097/pts.0000000000000525] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Our objective was to determine disagreement rates in radiological reports provided by using a double-reading protocol in a national teleradiology company. METHODS From January 2015 to July 2016, 134169 radiological exams from 36 French centers, benefited outsourced interpretations by certified radiologists, in both regular and after-hours activities. Of these, 2040 CT and MR-scans (1.5%) were subjected to a second opinion by other radiologists in the field of their anatomical specialty (cerebral, thoracic, abdominal-pelvic, and osteoarticular). A five-point agreement scale graded from 0 to 4 was assigned for each exam. Disagreements were considered as minor if no clinical consequence for patient (scores 1 and 2) and major if potential clinical consequence (score 3 and 4). Independent radiologists performed a retrospective analysis and a stratified statistical analysis. RESULTS Double reading was performed on CT-scans (n = 934/2040, 45.8%) and MR-scans (n = 1106/2040, 54.2%) performed in regular (80.1%) and after-hours activities (19.9%). Disagreement scores occurred in 437 exams (21.4%), including major disagreements in 59 (2.9%). Among these, 48/754 were assigned by the thoracic second reader (6.4%), 6/70 by the abdominal-pelvic second reader (8.6%), 3/901 by the osteoarticular second reader (0.3%), and 2/315 by the cerebral second reader (0.6%), with statistical significant difference. No additional disagreement rate was observed in regular and after-hours activities (P = 0.63). CONCLUSIONS Double-reading of outsourced CT and MRI interpretations yielded 21.4% disagreement rate, with potential clinical consequence for patient in 2,9% of the cases. These results are in accordance with those previously reported and suggests that quality assurance of outsourced interpretations is needed.
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Affiliation(s)
| | - Julien Frandon
- From the department of Radiology, Nîmes University Hospital, Nîmes, France
| | - Bastien Boussat
- Quality of care unit, Grenoble Alpes University Hospital, TIMC UMR 5525 CNRS, Grenoble Alpes University, France
| | - François Cotton
- Department of Radiology, Université de Lyon 1, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, 69495 Pierre Bénite Cedex, CREATIS INSA - 502, 69621 Villeurbanne Cedex, France
| | - Gilbert Ferretti
- Department of Medical Informatics, Centre Hospitalier et Universitaire de Grenoble, Hôpital Nord, Boulevard de la Chantourne, 38700 La Tronche, France
| | - Nicolas Sans
- Department of Radiology, Centre Hospitalier et Universitaire de Toulouse, Hôpital Pierre-Paul Riquet, Place du Docteur Baylac - TSA 40031, 31059 Toulouse cedex 9
| | - Jean-Pierre Tasu
- Department of radiology, Centre Hospitalier et Universitaire de Poitiers, Hôpital de la Milétrie, 2 Rue de la Milétrie, 86021 Poitiers cedex, France
| | - Jean-Paul Beregi
- From the department of Radiology, Nîmes University Hospital, Nîmes, France
| | - Ahmed Larbi
- From the department of Radiology, Nîmes University Hospital, Nîmes, France
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Dendl LM, Pausch AM, Hoffstetter P, Dornia C, Höllthaler J, Ernstberger A, Becker R, Kopf S, Schleder S, Schreyer AG. Structured Reporting of Whole-Body Trauma CT Scans Using Checklists: Diagnostic Accuracy of Reporting Radiologists Depending on Their Level of Experience. ROFO-FORTSCHR RONTG 2021; 193:1451-1460. [PMID: 34348402 DOI: 10.1055/a-1541-8265] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE Evaluation of the diagnostic accuracy of a checklist-style structured reporting template in the setting of whole-body multislice computed tomography in major trauma patients depending on the level of experience of the reporting radiologist. MATERIALS AND METHODS A total of 140 major trauma scans with the same protocol were included in this retrospective study. In a purely trial-intended reading, the trauma scans were analyzed by three radiologists with different levels of experience (resident, radiologist with 3 years of experience after board certification, and radiologist with 7 years of experience after board certification). The aim was to fill in the checklist 1 template within one minute to immediately diagnose management-altering findings. Checklist 2 was intended for the analysis of important trauma-related findings within 10 minutes. Reading times were documented. The final radiology report and the documented injuries in the patient's medical record were used as gold standard. RESULTS The evaluation of checklist 1 showed a range of false-negative reports between 5.0 % and 11.4 % with the resident showing the highest accuracy. Checklist 2 showed overall high diagnostic inaccuracy (19.3-35.0 %). The resident's diagnostic accuracy was statistically significantly higher compared to the radiologist with 3 years of experience after board certification (p = 0.0197) and with 7 years of experience after board certification (p = 0.0046). Shorter average reporting time resulted in higher diagnostic inaccuracy. Most of the missed diagnoses were fractures of the spine and ribs. CONCLUSION By using a structured reporting template in the setting of major trauma computed tomography, less experienced radiologists reach a higher diagnostic accuracy compared to experienced readers. KEY POINTS · In the setting of a pure trial reading, the diagnostic inaccuracy of template-based reporting of major trauma CT examinations is high.. · Fractures in general and especially of the vertebral bodies and ribs were the most commonly missed diagnoses.. · In a study setting, less experienced radiologists seem to reach a higher diagnostic accuracy when using a structured reporting approach.. CITATION FORMAT · Dendl LM, Pausch AM, Hoffstetter P et al. Structured Reporting of Whole-Body Trauma CT Scans Using Checklists: Diagnostic Accuracy of Reporting Radiologists Depending on Their Level of Experience. Fortschr Röntgenstr 2021; DOI: 10.1055/a-1541-8265.
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Affiliation(s)
- Lena Marie Dendl
- Institute for Diagnostic and Interventional Radiology, Brandenburg Medical School Theodor Fontane, Brandenburg a. d. Havel, Germany.,Department of Radiology, Johanniter-Hospital Treuenbrietzen, Germany
| | | | | | | | | | | | - Roland Becker
- Department of Orthopaedics and Traumatology, Medizinische Hochschule Brandenburg Theodor Fontane, Brandenburg an der Havel, Germany
| | - Sebastian Kopf
- Department of Orthopaedics and Traumatology, Medizinische Hochschule Brandenburg Theodor Fontane, Brandenburg an der Havel, Germany
| | - Stephan Schleder
- Department of Radiology, Barmherzige-Brüder-Klinikum Sankt Elisabeth Straubing GmbH, Straubing, Germany
| | - Andreas G Schreyer
- Institute for Diagnostic and Interventional Radiology, Brandenburg Medical School Theodor Fontane, Brandenburg a. d. Havel, Germany
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Miller JP, Ivanics C, Zalewski K, Mody SS, Kannikeswaran N. Rates and clinical impact of discordant X-ray and CT imaging in transfers to a pediatric emergency department. Am J Emerg Med 2021; 49:166-171. [PMID: 34126562 DOI: 10.1016/j.ajem.2021.05.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 05/13/2021] [Accepted: 05/23/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Children are often transferred to a Pediatric Emergency Department (PED) for definitive care after completion of diagnostic imaging. There is a paucity of data on the concordance rates of interpretation of imaging studies between referral and PED. Our objective is to describe the rates and clinical impact of discordant interpretation of X-rays and CT in children transferred to a PED. METHODS This was a retrospective cohort study of patients over a 12-month period from 12/1/2017-11/30/2018 with X-ray (XR) and CT performed prior to transfer to our PED. We compared referral radiology interpretations to those of pediatric radiologists to determine concordance. Encounters with discordant imaging interpretations were further evaluated for clinical impact (none, minor or major) based on need for additional laboratory workup, consultation, and changes in management and disposition. RESULTS We analyzed 899 patient encounters. There were high rates of concordance in both XR and CT interpretation (668/743; 89.9%, 95% CI 0.87-0.91 and 205/235; 87.2%, 95% CI 0.82-0.91, respectively). XR discordance resulted in minor clinical impact in 34 patients (45%, 95% CI 0.35-0.57) and a major clinical impact in 28 patients (37%, 95% CI 0.27-0.49). CT discordance resulted in minor clinical impact in 10 patients (33%, 95% CI 0.19-0.51) of patients and major clinical impact in 15 patients (50%, 95% CI 0.33-0.67). The most common discordances with major clinical impact were related to pneumonia on XR chest and appendicitis or inflammatory bowel disease on CT abdomen. CONCLUSIONS In patients transferred to the PED, concordance of XR and CT interpretations was high. A majority of discordant interpretations led to clinical impact meaningful to the patient and emergency medicine (EM) physician. Referring EM physicians might consider the benefit of pediatric radiology consultation upon transfer, especially for imaging diagnoses related to pneumonia, appendicitis, or inflammatory bowel disease.
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Affiliation(s)
- Jason P Miller
- Children's Hospital of Michigan, Division of Emergency Medicine, 3901 Beaubien Blvd, Detroit, MI 48201, United States; Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI 48201, United States; Central Michigan University School of Medicine, 1280 East Campus Dr, Mt Pleasant, MI 48858, United States.
| | - Ciara Ivanics
- Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI 48201, United States
| | - Kristina Zalewski
- Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI 48201, United States
| | - Swati S Mody
- Wayne State University School of Medicine, 540 E Canfield St, Detroit, MI 48201, United States; Children's Hospital of Michigan, Department of Radiology, 3901 Beaubien Blvd, Detroit, MI 48201, United States
| | - Nirupama Kannikeswaran
- Children's Hospital of Michigan, Division of Emergency Medicine, 3901 Beaubien Blvd, Detroit, MI 48201, United States; Central Michigan University School of Medicine, 1280 East Campus Dr, Mt Pleasant, MI 48858, United States
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8
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Emergency Computed Tomography: How Misinterpretations Vary According to the Periods of the Nightshift? J Comput Assist Tomogr 2021; 45:248-252. [PMID: 33512854 DOI: 10.1097/rct.0000000000001128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the accuracy of initial computed tomography (CT) interpretations made by radiology residents during nightshifts in the emergency department. METHODS Preliminary CT reports performed by radiology residents during 120 consecutive nightshifts (08:30 pm to 08:30 am) were reviewed, attendings' final interpretation being the reference standard. Nightshifts were divided into four consecutive periods of 3 hours. Major misinterpretations were related to potentially life-threatening conditions if not treated immediately after CT. The rate of misinterpretations was calculated for all CT examinations, separately for nightshift's periods and for residents' training years. RESULTS Misinterpretations were recorded in 155 (7.4%) of 2102 CT examinations, 0.6% (13/2102) were major. There were 2.2% (4/186) major misinterpretations that occurred during the last period of the nightshift versus 0.4% (9/1916) during the first periods of the night (P < 0.05). Of all misinterpretations, 8.5% (130/1526) were made by third- and fourth-year residents and 4.3% (25/576) by fifth-year residents (P < 0.005). CONCLUSIONS Major misinterpretations occur at the end of the nightshift, which may be explained by the fatigue effect. The rate of misinterpretations is lower among fifth-year residents, which may be related to their prior experience in reading emergency cases.
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Mughli RA, Durrant E, Baia Medeiros DT, Shelton D, Robins J, Qamar SR, O'Keeffe ME, Berger FH. Overnight attending radiologist coverage decreases imaging-related emergency department recalls by at least 90. Emerg Radiol 2021; 28:549-555. [PMID: 33428044 DOI: 10.1007/s10140-020-01894-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 12/22/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE Benefits of overnight attending radiologist final reports are debated, often stating low resident discrepancy rates, usually assessed retrospectively. The objective of this study was to assess the impact of overnight final reporting on the recall rates for patients in the emergency department (ED) receiving overnight imaging. METHODS Retrospective matched cohorts of two separate years prior (prior-16 and prior-17) and 1 year after (post-18) introduction of overnight attending radiologist final reporting. Patients receiving imaging between 22:00 and 07:00 h and returned to ED within 48 h of initial visit discharge were electronically identified. String matching identified return visits possibly related to imaging completed on first visit. Identified return visit notes were scored by three observers individually. Unclear and discrepant cases were resolved by consensus meeting, using full patient charts where needed. Incidences were provided and logistic regression analysis defined if coverage model was a predictor for recall. Odds ratios were calculated. RESULTS ED patient count with imaging completed overnight in prior-16 was 9200, in prior-17 was 9543, and in post-18 was 9992. The number of overnight imaging studies performed was respectively 13,883, 14,463, and 15,112. Imaging-related ED recalls were respectively 54, 61, and 7, a decrease with the new coverage model of 89% to true and at least 90% of expected recalls.Logistic regression demonstrated that coverage model was a significant predictor of ED recalls with chi-square of 59.86 and p < 0.001, an R2 of 0.03 (Hosmer and Lemeshow). Compared to post-18, ED patients had an odds ratio of 8.42 (prior-16) and 9.18 (prior-17) to be called back to ED. CONCLUSION Overnight final reporting significantly decreases ED recalls for patients receiving diagnostic imaging overnight. While numbers are low even prior to rollout, the number should be minimized wherever possible to diminish patient anxiety and discomfort, reduce ED overcrowding and expedite definitive management. KEY MESSAGES/WHAT THIS PAPER ADDS Section 1: What is already known on this subject • Radiology resident preliminary report discrepancy rates are low. • Overnight attending radiologist coverage is a model increasingly applied in academic and large non-academic centers. • Patient recalls to the ED are a burden to the patient and impact patient throughput in (over)crowded EDs. Section 2: What this study adds • First study to look at the impact of overnight attending final reports on the recall rate for ED patients with overnight imaging performed. • While absolute numbers are low, there is a significant decrease in patients returning to ED for imaging related issues after introducing overnight attending coverage. • Resident autonomy can be preserved and training enhanced while increasing patient safety and comfort.
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Affiliation(s)
- Rawan Abu Mughli
- Department of Medical Imaging, Division of Emergency & Trauma Radiology, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, Ontario, M4N3M5, Canada
| | - Eric Durrant
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | | | - Dominick Shelton
- Department of Emergency Services, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jason Robins
- Department of Medical Imaging, Division of Emergency & Trauma Radiology, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, Ontario, M4N3M5, Canada
| | - Sadia R Qamar
- Department of Medical Imaging, Division of Emergency & Trauma Radiology, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, Ontario, M4N3M5, Canada
| | - Michael E O'Keeffe
- Department of Medical Imaging, Division of Emergency & Trauma Radiology, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, Ontario, M4N3M5, Canada
| | - Ferco H Berger
- Department of Medical Imaging, Division of Emergency & Trauma Radiology, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Avenue, Toronto, Ontario, M4N3M5, Canada.
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Sawyer DM, Mushtaq R, Vedantham S, Shareef F, Desoky SM, Arif-Tiwari H, Gilbertson-Dahdal DL, Udayasankar UK. Performance of overnight on-call radiology residents in interpreting unenhanced abdominopelvic magnetic resonance imaging studies performed for pediatric right lower quadrant abdominal pain. Pediatr Radiol 2021; 51:1378-1385. [PMID: 33688988 PMCID: PMC8266720 DOI: 10.1007/s00247-021-05009-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 12/22/2020] [Accepted: 02/08/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Abdominopelvic magnetic resonance imaging (MRI) is increasingly being used to evaluate children with abdominal pain suspected of having acute appendicitis. At our institution, these examinations are preliminarily interpreted by radiology residents, especially when performed after hours. OBJECTIVE To determine the accuracy of preliminary reports rendered by radiology residents in this setting. MATERIALS AND METHODS Three hundred seventy-seven pediatric abdominopelvic MRI examinations were included. The preliminary (resident) and final (attending) radiology reports were coded as diagnosing acute appendicitis or no acute appendicitis. The concordance between resident and attending radiologist interpretations was calculated. Additionally, both resident and attending reports were compared to available surgical pathology or clinical follow-up data. RESULTS Overall concordance rate for the diagnosis of acute appendicitis was 97.1%. Concordance for verified cases of acute appendicitis was 93.4%. Concordance rates did not differ by residents' postgraduate year levels. When compared against surgical pathology or clinical follow-up data, residents demonstrated 91.2% sensitivity and 97.6% specificity. There was no statistically significant difference in the sensitivity or specificity of resident or attending radiologist interpretations. CONCLUSION Radiology residents demonstrate high concordance with attending pediatric radiologists in their interpretations of pediatric abdominopelvic MRI for acute appendicitis. The diagnostic performances of residents and attendings were comparable.
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Affiliation(s)
- David M. Sawyer
- Department of Medical Imaging, University of Arizona, 1501 N. Campbell, P.O. Box 245067, Tucson, AZ 85724 USA
| | - Raza Mushtaq
- Department of Medical Imaging, University of Arizona, 1501 N. Campbell, P.O. Box 245067, Tucson, AZ 85724 USA
| | - Srinivasan Vedantham
- Department of Medical Imaging, University of Arizona, 1501 N. Campbell, P.O. Box 245067, Tucson, AZ 85724 USA
| | - Faryal Shareef
- Creighton University of Arizona Health Alliance, Phoenix, AZ USA
| | - Sara M. Desoky
- Department of Medical Imaging, University of Arizona, 1501 N. Campbell, P.O. Box 245067, Tucson, AZ 85724 USA
| | - Hina Arif-Tiwari
- Department of Medical Imaging, University of Arizona, 1501 N. Campbell, P.O. Box 245067, Tucson, AZ 85724 USA
| | | | - Unni K. Udayasankar
- Department of Medical Imaging, University of Arizona, 1501 N. Campbell, P.O. Box 245067, Tucson, AZ 85724 USA
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Jo SY, Scanlon M, Cook T. Preliminary Radiology Report Discordances and Patient Outcomes. J Am Coll Radiol 2020; 17:1621-1625. [PMID: 32768423 DOI: 10.1016/j.jacr.2019.12.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 12/21/2019] [Accepted: 12/23/2019] [Indexed: 11/18/2022]
Abstract
RATIONALE AND OBJECTIVES At our institution, resident and fellow radiologists issue preliminary reports for off-hours imaging studies, which are overread by attending radiologists the next day using structured discrepancy templates. In this study, we examined the impact on patient management and outcome of studies with major discordance. MATERIALS AND METHODS For our retrospective observational study, preliminary reports between March and June 2017 that received major discordance were identified through report text search. Electronic medical records were reviewed for patient management change and patient outcome. RESULTS Of the 199 cases, 52 cases (26%) had management change and 119 cases (60%) did not have management change. In 25 cases (13%), the preliminary report was proven correct on subsequent management. Three cases (2%) were lost to follow-up. In only one case was adverse outcome directly related to the discordant finding. In cases with patient management change, there was higher proportion of perceptual error compared with those without management change (73% versus 59%). In 47 cases (24%), the discordant finding or diagnosis was known to the clinical team, and better history could have avoided the major change. CONCLUSION Adverse outcome from the discordant imaging finding was low (0.5%). Major change in preliminary report could be reduced with better clinical history. Patient management change was more frequently seen with perceptual errors, placing greater emphasis on strategies to reduce them.
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Affiliation(s)
| | - Mary Scanlon
- Vice Chair of Education, Chairperson, Radiation Safety Committee, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Tessa Cook
- Assistant Professor of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Co-Director, Center for Practice Transformation; Fellowship Director, Imaging Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Jalal S, Ouellette H, Ante Z, Munk P, Khosa F, Nicolaou S. Impact of 24/7/365 Attending Radiologist Coverage on the Turnaround Time in an Emergency and Trauma Radiology Department. Can Assoc Radiol J 2020; 72:548-556. [PMID: 32103671 DOI: 10.1177/0846537119899321] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To study the impact of 24/7/365 attending radiologist coverage on the turnaround time (TAT) of trauma and nontrauma cases in an emergency and trauma radiology department. PATIENTS AND METHODS This was a retrospective chart review in which TAT of patients coming to the emergency department between 2 periods: (1) December 1, 2012, to September 30, 2013, and (2) January 1, 2017, to January 30, 2018, and whose reports were read by an attending emergency and trauma radiologist was noted. RESULTS The 24/7/365 radiology coverage was associated with a significant reduction in TAT of computed tomography reports, and the time reduction was comparable between trauma and nontrauma cases. In adjusted models, the extension of radiology coverage was associated with an average of 7.83 hours reduction in overall TAT (95% confidence interval [CI]: 7.44-8.22) for reports related to trauma, in which 2.73 hours were due to reduction in completion to transcription time (TC; 95% CI: 2.53-2.93), and 5.10 hours were due to reduction in transcription to finalization time (TF; 95% CI: 4.75-5.44). For reports related to nontrauma cases, 24/7/365 coverage was associated with an average of 6.07 hours reduction in overall TAT (95% CI: 3.54-8.59), 2.91 hours reduction in TC (95% CI: 1.55-4.26), and 3.16 hours reduction in TF (95% CI: 0.90-5.42). CONCLUSION Our pilot study demonstrates that the implementation of on-site 24/7/365 attending emergency radiology coverage at a tertiary care center was associated with a reduced TAT for trauma and nontrauma patients imaging studies. Although the magnitude and precision of estimates were slightly higher for trauma cases as compared to nontrauma cases. Trauma examinations stand to benefit the most from 24/7/365 attending level radiology coverage.
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Affiliation(s)
- Sabeena Jalal
- Department of Radiology, 8167Vancouver General Hospital, Vancouver, British Columbia, Canada.,McGill University, Montreal, Quebec, Canada
| | - Hugue Ouellette
- Department of Radiology, 8167Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Peter Munk
- Department of Radiology, 8167Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Faisal Khosa
- Department of Radiology, 8167Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Savvas Nicolaou
- Department of Radiology, 8167Vancouver General Hospital, Vancouver, British Columbia, Canada
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Jalal S, Lloyd ME, Khosa F, I-Hsuan Hsu G, Nicolaou S. Exploratory data analysis for pre and post 24/7/365 attending radiologist coverage support in an emergency department: fundamentals of data science. Emerg Radiol 2019; 27:233-251. [PMID: 31840209 DOI: 10.1007/s10140-019-01737-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 10/22/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To present a detailed exploratory data analysis for critically investigating the patterns in medical doctor (MD) to disposition time, pre and post 24/7/365 attending radiologist coverage, for patients presenting to an emergency department (ED). MATERIALS AND METHODS The process involved presenting several modeling techniques. To share an understanding of concepts and techniques, we used proportions, medians, and means, Mann-Whitney U test, Kaplan-Meier's (KM) survival analysis, linear and log-linear regression, log-ranked test, Cox proportional hazards model, Weibull parametric survival models and tertile analysis. Retrospective chart review was conducted to obtain a data set which was used to determine the trends in MD to disposition time. Data comprised of patients who had visited the emergency department (ED) during two distinct time periods and whose imaging studies were read by an attending emergency and trauma radiologist. RESULTS Median provided more insight into the data as compared with the mean. The Mann-Whitney U test was appropriate to evaluate MD to disposition time, but provided limited information. The Kaplan-Meier (KM) was able to offer more insight into the data since it did not assume an underlying model and that is the reason why it was appropriate. However, KM had limited ability to handle measured confounders and was unable to describe the magnitude of difference between curves. The Cox proportional hazards semi-parametric model or some other parametric model such as the Weibull could handle multiple measured confounders and described the magnitude of difference between two (survival) groups in the data set. However, both methods assumed underlying models that may not apply to the data set such as the one used in this study. Linear regression was unlikely to be appropriate due to the shape of survival time distributions, but log transforming the outcome could address the distribution issue. Nearly all the results of the KM subgroup analyses were consistent with the results of the log-transformed linear regression subgroup analyses and the interpretation of the results was the same for both. CONCLUSION Different statistical procedures may be applied to conduct exploratory subgroup analysis for a data set from a pre and post 24/7/365 attending coverage model. This could guide potential areas of further research to compare trends in MD to disposition time in ED. Pattern analysis provides evidence for various stakeholders to rethink the discourse about trends in MD to disposition time, pre and post 24/7/365 attending coverage. Graphical Illustration: The role of Emergency and Trauma Radiology in an Emergency Department.
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Affiliation(s)
- Sabeena Jalal
- Emergency & Trauma Radiology, Department of Radiology, Vancouver General Hospital, Vancouver, Canada. .,McGill University, Montréal, Canada.
| | | | - Faisal Khosa
- Emergency & Trauma Radiology, Department of Radiology, Vancouver General Hospital, Vancouver, Canada
| | | | - Savvas Nicolaou
- Emergency & Trauma Radiology, Department of Radiology, Vancouver General Hospital, Vancouver, Canada
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Second opinions in orthopedic oncology imaging: can fellowship training reduce clinically significant discrepancies? Skeletal Radiol 2019; 48:143-147. [PMID: 30003278 DOI: 10.1007/s00256-018-3024-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 05/12/2018] [Accepted: 06/28/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine factors that lead to significant discrepancies in second-opinion consultation of orthopedic oncology patients, and particularly if musculoskeletal fellowship training can decrease clinically significant discrepancies. METHODS A PACS database was queried for secondary reads on outside cross-sectional imaging studies, as requested by orthopedic oncology from 2014 to 2017. Comparison of original and secondary reports was performed using a published seven-point scale that defines clinically significant discrepancies. An online search was performed for each original radiologist to record if a fellowship in musculoskeletal imaging was completed. Additionally, years of post-residency experience, number of Medicare part B patients billed per year (marker of practice volume), and average hierarchical condition category for each radiologist (marker of practice complexity) was recorded. RESULTS A total of 571 patients met the inclusion criteria, with 184 cases initially interpreted by an outside fellowship trained musculoskeletal (MSK) radiologist and 387 cases initially interpreted by a non-MSK trained radiologist. The rate of clinically significant discrepancy was 9.2% when initially interpreted by MSK radiologists compared with 27.9% when initially performed by non-MSK radiologists (p < 0.05). After adjustment by both patient characteristics and radiologist characteristics, the likelihood of clinically significant discrepancies was greater for initial interpretations by non-MSK radiologists compared with MSK radiologists (OR = 1.36; 95% CI = 1.23-2.49). CONCLUSION In orthopedic oncology patients, the rate of clinically significant discrepancies was significantly higher when initially interpreted by non-MSK radiologists compared with MSK radiologists. The lower rate of clinically significant discrepancies demonstrates that subspecialty training may direct more appropriate diagnosis and treatment.
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Wildman-Tobriner B, Cline B, Swenson C, Allen BC, Maxfield CM. Evaluating Resident On-Call Performance: Does Volume Affect Discrepancy Rate? Curr Probl Diagn Radiol 2018; 47:364-367. [DOI: 10.1067/j.cpradiol.2017.12.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 11/09/2017] [Accepted: 12/12/2017] [Indexed: 11/22/2022]
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The Clinical Impact of Resident-attending Discrepancies in On-call Radiology Reporting: A Retrospective Assessment. Acad Radiol 2018; 25:727-732. [PMID: 29337090 DOI: 10.1016/j.acra.2017.11.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 11/22/2017] [Indexed: 11/23/2022]
Abstract
RATIONALE AND OBJECTIVES The purpose of this study is to quantify the clinical impact of resident-attending discrepancies at a tertiary referral academic radiology residency program by assessing rates of intervention, discrepancy confirmation, recall rate, and management change rate; furthermore, a discrepancy categorization system will be assessed. MATERIALS AND METHODS Retrospective review of the records was performed for n = 1482 discrepancies that occurred in the 17-month study period to assess the clinical impact of discrepancies. Discrepancies were grouped according to a previously published classification system. Management changes were recorded and grouped by severity. The recall rate was estimated for discharged patients. Any confirmatory testing was reviewed to evaluate the accuracy of the discrepant report. Categorical variables were compared to the chi-square test. RESULTS The 1482 discrepancies led to management change in 661 cases (44.6%). The most common management change was follow-up imaging. Procedural interventions including surgery occurred in 50 cases (3.3%). The recall rate was 2.6%. Management changes were more severe with computed tomography examinations, inpatients, and when the discrepancy was in the chest and abdomen subspecialty. Also, management changes correlated with the discrepancy category assigned by the attending at the time of review. CONCLUSIONS Resident-attending discrepancies do cause management changes in 44.6% of discrepancies (0.62% overall); the most frequent change is follow-up imaging. The discrepancy categorization assigned by the attending correlated with the severity of management change.
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Abstract
BACKGROUND Clinical impact of radiology callbacks (missed initial radiologic diagnosis) remains largely unknown in the pediatric emergency department (PED). OBJECTIVE The aim of this study was to describe the incidence, nature of radiology callbacks, and the impact on clinical care during the return visit (RV). METHODS We performed a retrospective chart review of quality assurance database of RVs for radiology callbacks to our PED over a 1-year period. RESULTS Return visit rate to our PED was 3% (2765/92,000) of which 1.9% (55/2765) was for radiology callbacks. Radiology misses involved mostly x-ray interpretations (92.7%), occurred after-hours (83.6%), with fractures being the most common missed finding. Majority of patients (94.5%) required 1 or more interventions during the RV; 34.5% of radiology callbacks had a major impact on clinical management; 27.2% of radiology callbacks were false-positive. CONCLUSIONS Although RVs secondary to radiology callback remain low, one third of them resulted in major changes in diagnosis, treatment, or disposition and impacted patient outcome.
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Wildman-Tobriner B, Allen BC, Maxfield CM. Common Resident Errors When Interpreting Computed Tomography of the Abdomen and Pelvis: A Review of Types, Pitfalls, and Strategies for Improvement. Curr Probl Diagn Radiol 2018; 48:4-9. [PMID: 29397268 DOI: 10.1067/j.cpradiol.2017.12.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 11/09/2017] [Accepted: 12/12/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The purpose of this study was to identify common errors that radiology residents make when interpreting abdominopelvic (AP) computed tomography (CT) while on call, to review the typical imaging findings of these cases, and to discuss strategies for improvement. MATERIALS AND METHODS AP (or chest, abdomen, pelvis) CTs from 518 weekend senior call shifts (R3 or R4) were retrospectively reviewed. Discrepancies between preliminary and final reports were identified and then rated by whether the miss could impact short-term management. The imaging findings from the cases were reviewed. RESULTS A total of 4695 CTs were reviewed, revealing a total of 145 discrepancies that could affect short-term clinical management (miss rate 3.1%). The most common misses were related to blood clots (13.8%), colitis (8.3%), misplaced lines or tubes (6.9%), or pyelonephritis (5.5%). Common pitfalls and strategies from improved detection are discussed using image examples. CONCLUSIONS Through increased attention to the vasculature, colon, devices, and kidneys, trainees may improve their discrepancy rates and improve on-call reporting.
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Affiliation(s)
| | - Brian C Allen
- Department of Radiology, Duke University Hospital, Durham, NC
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Mangona KLM, Guillerman RP, Mangona VS, Carpenter J, Zhang W, Lopez M, Orth RC. Diagnostic Performance of Ultrasonography for Pediatric Appendicitis: A Night and Day Difference? Acad Radiol 2017; 24:1616-1620. [PMID: 28826614 DOI: 10.1016/j.acra.2017.06.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Revised: 03/06/2017] [Accepted: 06/05/2017] [Indexed: 01/07/2023]
Abstract
RATIONALE AND OBJECTIVES For imaging pediatric appendicitis, ultrasonography (US) is preferred because of its lack of ionizing radiation, but is limited by operator dependence. This study investigates the US diagnostic performance during night shifts covered by radiology trainees compared to day shifts covered by attending radiologists. MATERIALS AND METHODS Appy-Scores (1 = completely visualized normal appendix; 2 = partially visualized normal appendix; 3 = nonvisualized appendix with no inflammatory changes in the expected region of the appendix; 4 = equivocal; 5a = nonperforated appendicitis; 5b = perforated appendicitis) from 2935 US examinations (2161:774, day-to-night) from July 2013 to 2014 were correlated with the intraoperative diagnoses and the clinical follow-up. The diagnostic performance of trainees and attendings was compared with Fisher exact test. Interobserver agreement was measured by Cohen kappa coefficient. RESULTS Appendicitis prevalence was 25.3% (day) and 22.5% (night). Sensitivity, specificity, accuracy, negative predictive value, and positive predictive vale were 94.0%, 93.7%, 93.8%, 97.9%, and 83.4% during the day and 92.0%, 91.2%, 91.3%, 97.5%, and 75.2% at night. Specificity (P = .048) and positive predictive value (P = .011) differed, with more false positives at night (7%) than during the day (4.7%). Trainee and attending agreement was high (k = 0.995), with Appy-Scores of 1, 4, and 5a most frequently discordant. CONCLUSIONS US has a high diagnostic performance and interobserver agreement for pediatric appendicitis when interpreted by radiology trainees during night shifts or attending radiologists during day shifts. However, lower specificity and positive predictive value at night warrants a thorough trainee education to avoid false-positive examinations.
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Affiliation(s)
- Kate Louise M Mangona
- Baylor College of Medicine, Department of Pediatric Radiology, Texas Children's Hospital, Texas Medical Center (Clinical Care Tower, 470), 6701 Fannin Street, Houston, TX 77030.
| | - R Paul Guillerman
- Baylor College of Medicine, Department of Pediatric Radiology, Texas Children's Hospital, Texas Medical Center (Clinical Care Tower, 470), 6701 Fannin Street, Houston, TX 77030.
| | - Victor S Mangona
- Department of Radiation Oncology, The University of Texas MD. Anderson Cancer Center, Houston, Texas
| | - Jennifer Carpenter
- Texas children's hospital, Department of surgery, Division of pediatric surgery, Houston, Texas
| | - Wei Zhang
- Texas Children's Hospital Outcomes & Impact Service, Houston, Texas
| | - Monica Lopez
- Division of Pediatric Surgery, Baylor College of Medicine, Houston, Texas
| | - Robert C Orth
- Baylor College of Medicine, Department of Pediatric Radiology, Texas Children's Hospital, Texas Medical Center (Clinical Care Tower, 470), 6701 Fannin Street, Houston, TX 77030
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Preliminary Interpretations of Transthoracic Echocardiograms by Cardiology Fellows. J Am Soc Echocardiogr 2017; 30:1234-1238. [PMID: 28870437 DOI: 10.1016/j.echo.2017.07.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND Echocardiograms are often obtained after business hours on an urgent or emergent basis to assist in the care of patients with complex presentations. Considerable variation exists among academic medical centers with regard to who performs and interprets these studies, with different levels of cardiology fellow involvement in scanning and/or interpreting. On-call echocardiographic interpretation can be educationally valuable for cardiologists in training but may come at the expense of patient care. The aim of this study was to examine the agreement of preliminary fellows' interpretations of weekend on-call transthoracic echocardiograms with official attending cardiologists' interpretations. METHODS Cardiology fellows perform preliminary interpretations of sonographer-obtained echocardiograms obtained on weekends, with final reports performed by attending cardiologists the following business day. In this study, 358 consecutive echocardiograms obtained on weekends over a 12-month period were reviewed. Discrepancies between the preliminary and final interpretations were categorized as either major (diagnoses with implications for urgent change in management) or minor (diagnoses without such implications). All discrepancies were also categorized as a missed diagnosis, an overcall (of severity), or an undercall. RESULTS No preliminary interpretation was identified in 18.4% of the studies (66 of 358). Of the remaining on-call echocardiograms (n = 292), the overall discrepancy rate in interpretations between fellows and attending cardiologists was 16.8%. Out of these, the minor discrepancy rate was 14.4% (42 of 292), and the major discrepancy rate was 2.4% (seven of 292). Misses, overcalls, and undercalls accounted for 29%, 31%, and 40% of all discrepancies, respectively. CONCLUSIONS The results indicate that although minor discrepancies between fellows' and attending cardiologists' interpretations were common (14.4%), major discrepancies were uncommon (2.4%) and similar to major discrepancy rates from the radiology literature. In general, discrepant interpretations were more likely to result from changes in severity, but misses accounted for almost all of the major discrepancies. Further research is needed to compare the clinical impact of different models of on-call echocardiographic services.
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Rozenberg A, Kenneally BE, Abraham JA, Strogus K, Roedl JB, Morrison WB, Zoga AC. Clinical Impact of Second-Opinion Musculoskeletal Subspecialty Interpretations During a Multidisciplinary Orthopedic Oncology Conference. J Am Coll Radiol 2017; 14:931-936. [DOI: 10.1016/j.jacr.2017.01.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 01/07/2017] [Accepted: 01/09/2017] [Indexed: 10/20/2022]
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Zygmont ME, Shekhani H, Kerchberger JM, Johnson JO, Hanna TN. Point-of-Care Reference Materials Increase Practice Compliance With Societal Guidelines for Incidental Findings in Emergency Imaging. J Am Coll Radiol 2016; 13:1494-1500. [DOI: 10.1016/j.jacr.2016.07.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 07/25/2016] [Accepted: 07/27/2016] [Indexed: 12/21/2022]
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Coleman S, Holalkere NS, O׳Malley J, Doherty G, Norbash A, Kadom N. Radiology 24/7 In-House Attending Coverage: Do Benefits Outweigh Cost? Curr Probl Diagn Radiol 2016; 45:241-6. [DOI: 10.1067/j.cpradiol.2016.02.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Accepted: 02/16/2016] [Indexed: 11/22/2022]
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Harvey HB, Alkasab TK, Prabhakar AM, Halpern EF, Rosenthal DI, Pandharipande PV, Gazelle GS. Radiologist Peer Review by Group Consensus. J Am Coll Radiol 2016; 13:656-62. [DOI: 10.1016/j.jacr.2015.11.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 11/10/2015] [Accepted: 11/14/2015] [Indexed: 10/22/2022]
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Second-Opinion Subspecialty Consultations in Musculoskeletal Radiology. AJR Am J Roentgenol 2016; 206:1217-21. [PMID: 27058462 DOI: 10.2214/ajr.15.14540] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this article is to evaluate the significance of subspecialty second-opinion consultations for CT and MRI examinations in musculoskeletal (MSK) radiology. MATERIALS AND METHODS All 3165 MSK CT and MRI examinations referred to one academic institution for second-opinion consultation during a 24-month period were reviewed by three MSK-trained radiologists. Outside and inside reports were compared by two independent MSK radiology fellows using a previously published 5-point scale. Clinically important differences (categories 4 and 5) were defined as those likely to change patient management. Statistical comparisons of rates were performed using a chi-square test with Bonferroni corrections. Interobserver reliability was reported using linear weighted kappa statistics and the percentage of agreement. RESULTS Of all second-opinion examinations, 73.5% (2326/3165) had an outside report available for comparison and inclusion in this study. There were 610 of 2326 (26.2%) examinations with clinically important differences. The rate of clinically important discrepant readings was even higher in oncologic cases (36.3%; 331/911). When the final diagnosis was determined from pathology reports performed after internal interpretation, the second-opinion consultation was noted to be correct in 82.0% (334/407) of examinations with category 4 or 5 discrepancies. There was very good agreement (κ = 0.93) in scoring the discrepancies between second-opinion consultants. CONCLUSION The subspecialty second-opinion consultation was more accurate than outside reports in 82.0% of examinations when pathologic confirmation was made. A moderate rate (26.2%) of discrepant interpretations was noted between outside and inside MSK imaging examinations, especially in tumor cases (36.3%). Most discrepancies were in interpreting rather than detecting abnormalities.
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Inefficient Resource Use for Patients Who Receive Both a Chest Radiograph and Chest CT in a Single Emergency Department Visit. J Am Coll Radiol 2016; 13:21-7. [DOI: 10.1016/j.jacr.2015.06.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 06/18/2015] [Indexed: 11/23/2022]
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Abstract
Approximately 4 % of radiologic interpretation in daily practice contains errors and discrepancies that should occur in 2-20 % of reports. Fortunately, most of them are minor degree errors, or if serious, are found and corrected with sufficient promptness; obviously, diagnostic errors become critical when misinterpretation or misidentification should significantly delay medical or surgical treatments. Errors can be summarized into four main categories: observer errors, errors in interpretation, failure to suggest the next appropriate procedure, failure to communicate in a timely and a clinically appropriate manner. Misdiagnosis/misinterpretation percentage should rise up in emergency setting and in the first moments of the learning curve, as in residency. Para-physiological and pathological pitfalls in neuroradiology include calcification and brain stones, pseudofractures, and enlargement of subarachnoid or epidural spaces, ventricular system abnormalities, vascular system abnormalities, intracranial lesions or pseudolesions, and finally neuroradiological emergencies. In order to minimize the possibility of error, it is important to be aware of various presentations of pathology, obtain clinical information, know current practice guidelines, review after interpreting a diagnostic study, suggest follow-up studies when appropriate, communicate significant abnormal findings appropriately and in a timely fashion directly with the treatment team.
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Issa G, Taslakian B, Itani M, Hitti E, Batley N, Saliba M, El-Merhi F. The discrepancy rate between preliminary and official reports of emergency radiology studies: a performance indicator and quality improvement method. Acta Radiol 2015; 56:598-604. [PMID: 24833644 DOI: 10.1177/0284185114532922] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Accepted: 04/01/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND At teaching hospitals, radiology residents give preliminary reports for imaging studies requested from the Emergency Department (ED). Discrepancy rates between preliminary and final reports represent an important performance indicator. PURPOSE To present a system for feedback and follow-up of discrepancies, identify the variables associated with the rate and severity of such discrepancies, target the weaknesses, and suggest the need of a standard reference value for comparison among institutions. MATERIAL AND METHODS A monitoring and communication system between the Department of Diagnostic Radiology and Emergency Department was initiated to mark and follow all studies from the ED for which the official reading was different than the preliminary interpretation. Data analysis was performed on all studies from 1 June 2011 to 31 May 2012, based on the severity of the discrepancy, imaging modality, resident training level, and organ system. The distribution of the number of discrepancies among the different resident levels and imaging modalities was determined, as well as the distribution of three severity scores in correlation with other variables. RESULTS The overall discrepancy rate was 1.62%. The discrepancy rate was higher for first and second year residents (1.62% and 1.96%) than for third and fourth year residents (1.35% and 1.24%). It was higher for computed tomography (2.13%) than for radiographs (1.29%) and ultrasound (0.8%) (P value < 0.01), and higher for musculoskeletal (1.61%) than non-musculoskeletal (0.99%) radiographs (P value = 0.0003). Discrepancies with severity score one constituted 35.5% of the total discrepancies, those with severity scores two and three constituted 22.9% and 41.6%, respectively. CONCLUSION We have demonstrated a system for follow-up of discrepancy in interpreting emergency radiology studies, and recorded the discrepancy rate, with further analysis based on different variables. In terms of quality assurance, a periodical analysis might help to reduce the number of discrepant reports by targeted intervention.
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Affiliation(s)
- Ghada Issa
- Department of Diagnostic Radiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Bedros Taslakian
- Department of Diagnostic Radiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Malak Itani
- Department of Diagnostic Radiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Eveline Hitti
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nicholas Batley
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Miriam Saliba
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Fadi El-Merhi
- Department of Diagnostic Radiology, American University of Beirut Medical Center, Beirut, Lebanon
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Garrett KG, De Cecco CN, Schoepf UJ, Silverman JR, Krazinski AW, Geyer LL, Lewis AJ, Headden GF, Ravenel JG, Suranyi P, Meinel FG. Residents' performance in the interpretation of on-call "triple-rule-out" CT studies in patients with acute chest pain. Acad Radiol 2014; 21:938-44. [PMID: 24928163 DOI: 10.1016/j.acra.2014.04.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 04/25/2014] [Accepted: 04/29/2014] [Indexed: 10/25/2022]
Abstract
RATIONALE AND OBJECTIVES To evaluate the performance of radiology residents in the interpretation of on-call, emergency "triple-rule-out" (TRO) computed tomographic (CT) studies in patients with acute chest pain. MATERIALS AND METHODS The study was institutional review board-approved and Health Insurance Portability and Accountability Act compliant. Data from 617 on-call TRO studies were analyzed. Dedicated software enables subspecialty attendings to grade discrepancies in interpretation between preliminary trainee reports and their final interpretation as "unlikely to be significant" (minor discrepancies) or "likely to be significant" for patient management (major discrepancies). The frequency of minor, major and all discrepancies in resident's TRO interpretations was compared to 609 emergent non-electrocardiography (ECG)-synchronized chest CT studies using Pearson χ(2) test. RESULTS Minor discrepancies occurred more often in the TRO group (9.1% vs. 3.9%, P < .001), but there was no difference in the frequency of major discrepancies (2.1% vs. 2.8%, P = .55). Minor discrepancies in the TRO group most commonly resulted from missed extrathoracic findings with missed liver lesions being the most frequent. Major discrepancies mostly encompassed cardiac and extracardiac vascular findings but did not result in unnecessary interventions, significant immediate changes in management, or adverse patient outcomes. CONCLUSIONS On-call resident interpretation of TRO CT studies in patients with acute chest pain is congruent with final subspecialty attending interpretation in the overwhelming majority of cases. The rate of discrepancies likely to affect patient management in this domain is not different from emergent non-ECG-synchronized chest CT.
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Dabbo S, Varner C, Bleakney R, Ovens H. Clinical impact of extending after-hours radiology coverage for emergency department computed tomography imaging. Open Access Emerg Med 2014; 6:33-5. [PMID: 27147877 PMCID: PMC4753985 DOI: 10.2147/oaem.s59750] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background Academic emergency departments (EDs) are often reliant on preliminary interpretation by radiology residents for after-hours computed tomography (CT) images. Identifying residents’ errors in diagnostic interpretation and ensuring appropriate contact with affected patients are areas of continuing concern. Objective The Mount Sinai Hospital ED and Medical Imaging Department in Toronto, Canada sought to examine the clinical impact of extending reporting hours of senior attending radiologists for ED patients undergoing CT imaging. Methods All evening CT studies were read by the on-call sub-specialist staff radiologist before 10 pm; while studies done after 10 pm were read by 8 am, permitting review of final reports by the ordering ED physician. A retrospective review of radiology and ED metrics was performed on ED patients undergoing CT imaging 12 weeks before and 12 weeks after implementation of the extended reading hours. Results In the 12 weeks prior to implementation of extended senior attending radiologist coverage, 871 CT scans were performed as compared to 944 CT scans after implementation. Time from performance of CT scan to obtaining a dictated report decreased from 10.4 hours to 2.8 hours (P<0.001), and time from performance of CT scan to report verification by the radiologist decreased from 29.7 hours to 9.4 hours (P<0.001). There were no statistically significant changes in ED length of stay, rates of admission, or rates of consultation. However, there was a significant reduction in (median) time taken for ED physicians to resolve discrepant reports in the radiology information system queue (20.7 hours versus 13.3 hours, P<0.001). Conclusion The extension of reporting hours reduced the time for ED physicians to review discrepant reports, while balancing educational needs of residents. This project has been considered a success by stakeholders and has now been implemented on a permanent basis.
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Affiliation(s)
- Samer Dabbo
- University Health Network, Department of Medical Imaging, University of Toronto, Canada
| | - Catherine Varner
- Division of Emergency Medicine, Schwartz/Reisman Emergency Medicine Institute, Mount Sinai Hospital, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | - Robert Bleakney
- University Health Network, Department of Medical Imaging, University of Toronto, Canada; Division of Emergency Medicine, Schwartz/Reisman Emergency Medicine Institute, Mount Sinai Hospital, Canada
| | - Howard Ovens
- Division of Emergency Medicine, Schwartz/Reisman Emergency Medicine Institute, Mount Sinai Hospital, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, Canada
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Swenson DW, Ellermeier A, Dibble EH, Movson JS, Egglin TK, Mainiero MB. Review of outside studies by radiology residents: national survey of chief residents. Emerg Radiol 2014; 21:479-84. [PMID: 24777574 DOI: 10.1007/s10140-014-1228-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 04/14/2014] [Indexed: 10/25/2022]
Abstract
The purpose of this study was to establish practice patterns of radiology residents in regards to interpretation and reporting of outside studies for transferred patients. We performed a national survey of radiology residency chief residents, administered by email through the Association of Program Directors in Radiology (APDR). There were 81 chief resident respondents, representing 42.8 % of 187 total Accreditation Council for Graduate Medical Education (ACGME)-approved radiology residency training programs in the USA. In 97.5 % of programs, residents perform interpretations of outside studies. Up to 76.7 % of respondents state that when outside studies are reviewed by residents, an original report is available in less than one quarter of cases. While 55.1 % of respondents state that there is a mechanism for recording their findings and impressions for outside studies, only 32.1 % are aware of a policy requiring documentation. Of the respondents, 42.3 % report they have no means for documenting their findings and impressions on outside studies. Further, 65.4 % state that there is no policy requiring an attending to review and document agreement with their interpretation of outside studies. There is wide institutional variation in both policy and practice regarding reinterpretation of outside studies for patients transferred to academic hospitals. While the majority of radiology residents are providing the service of reinterpreting outside studies, only a minority of residency programs have a policy requiring (1) documentation of their impressions or (2) attending oversight and documentation of discrepant opinions.
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Affiliation(s)
- David W Swenson
- Department of Diagnostic Imaging, Rhode Island Hospital, Alpert Medical School of Brown University, 593 Eddy St., Providence, RI, 02903, USA,
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Wu MZ, McInnes MDF, Macdonald DB, Kielar AZ, Duigenan S. CT in adults: systematic review and meta-analysis of interpretation discrepancy rates. Radiology 2013; 270:717-35. [PMID: 24475832 DOI: 10.1148/radiol.13131114] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
PURPOSE To use meta-analysis to determine the discrepancy rate when interpreting computed tomography (CT) studies performed in adult patients and to determine whether discrepancy rate differs on the basis of body region or level of radiologist training. MATERIALS AND METHODS MEDLINE and EMBASE were searched from 1946 to June 2012 by using the combination "radiology AND (error OR peer review)." Two reviewers independently selected studies that met the inclusion criteria and extracted study data. Total and major discrepancy rates were investigated with a random-effects meta-analysis, and subgroups were compared by using the χ(2) Q statistic. Subgroup analyses were performed on the basis of the level of training of the initial radiologist and the body system scanned. RESULTS Fifty-eight studies met the inclusion criteria (388 123 CT examinations). The pooled total discrepancy rate was 7.7% (95% confidence interval [CI]: 5.6%, 10.3%), and the major discrepancy rate was 2.4% (95% CI: 1.7%, 3.2%). The pooled major discrepancy rate was comparable for staff (2.9%; 95% CI: 1.2%, 6.7%) and residents (2.2%; 95% CI: 1.7%, 2.9%) (Q = 0.92, P = .633). The pooled major discrepancy rates for head CT (0.8%; 95% CI: 0.4%, 1.6%) and spine CT (0.7%; 95% CI: 0.2%, 2.7%) were lower than those for chest CT (2.8%; 95% CI: 1.5%, 5.4%) and abdominal CT (2.6%; 95% CI: 1.0%, 6.7%) (Q = 8.28, P = .041). Lack of blinding of the reference radiologist to the initial report was associated with a lower major discrepancy rate (2.0%; 95% CI: 1.4%, 2.7%; 43 studies) than when blinding was present (12.1%; 95% CI: 4.4%, 29.4%; five studies) (Q = 10.65, P = .001). CONCLUSION Potentially useful reference ranges were identified in the subgroup analyses on the basis of body region scanned at adult CT. However, considerable heterogeneity that is only partially explained by subgroup analysis signifies that further research is necessary--particularly regarding the question of blinding of the reference radiologist.
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Affiliation(s)
- Mark Z Wu
- From the Department of Medical Imaging, University of Ottawa Faculty of Medicine, Ottawa Hospital Research Institute, 1053 Carling Ave, Room c159, Ottawa, ON, Canada K1Y 4E9 (M.Z.W., M.D.F.M.); and Department of Medical Imaging, the Ottawa Hospital, University of Ottawa, Ottawa, Ont, Canada (D.B.M., A.Z.K., S.D.)
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Emergency imaging discrepancy rates at a level 1 trauma center: identifying the most common on-call resident “misses”. Emerg Radiol 2013; 20:499-505. [DOI: 10.1007/s10140-013-1146-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Accepted: 07/03/2013] [Indexed: 10/26/2022]
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Friedman SM, Merman E, Chopra A. Clinical impact of diagnostic imaging discrepancy by radiology trainees in an urban teaching hospital emergency department. Int J Emerg Med 2013; 6:24. [PMID: 23866048 PMCID: PMC3716958 DOI: 10.1186/1865-1380-6-24] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 07/01/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To characterize clinically significant diagnostic imaging (DI) discrepancies by radiology trainees and the impact on emergency department (ED) patients. METHODS Consecutive case series methodology over a 6-month period in an urban, tertiary care teaching hospital. Emergency physicians (EPs) were recruited to flag discrepant DI interpretations by radiology trainees that the EP deemed clinically significant. Cases were characterized using chart review and EP interview. RESULTS Twenty-eight discrepant reports were identified (representing 0.1% of 18,185 images interpreted). The mean time between provisional discrepant diagnosis (PDDx) and revised diagnosis (RDx) by attending radiology staff was 8.6 h (median 4.8 h, range 1.1-48.4), and 67.9% (n = 19) of the patients had left the ED by time of notification. The most frequently reported PDDx was CT abd/pelvis (32.1%, n = 9) and CT head (28.6%, n = 8). The impact of RDx was deemed major in 57.1% (n = 16) for reasons including altered admitting status (32.1%, n = 9), immediate subspecialty referral (n = 16, 57.1%), impact on management (25%, n = 7), and surgical management (21.4%, n = 6). EPs reported likely perceived impact of PDDx as resulting in increased pain (17. 9%, n = 5), morbidity (10.7%, n = 3), and prolonged hospitalization (25%, n = 7), but not altered long-term outcome or mortality. CONCLUSIONS Relatively few clinically important discrepant reads were reported. Revised diagnosis (RDx) was associated with major clinical impact in 57.1% of reports, but few patients experienced increased morbidity, and none increased mortality. The importance of expedient communication of discrepant reports by staff radiologists is stressed, as is EP verification of patient contact information prior to discharge.
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Affiliation(s)
- Steven Marc Friedman
- Emergency Medicine - University Health Network, Faculty of Medicine, University of Toronto, RFE G-S434, 200 Elzaibeth Street, Toronto, Ontario M5G 2C4, Canada.
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McNeeley MF, Gunn ML, Robinson JD. Transfer patient imaging: current status, review of the literature, and the Harborview experience. J Am Coll Radiol 2013; 10:361-7. [PMID: 23415656 DOI: 10.1016/j.jacr.2012.09.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Accepted: 09/24/2012] [Indexed: 11/28/2022]
Abstract
Patients transferred for higher levels of care often arrive with medical imaging from the outside facility, with or without accompanying radiology reports. The handling of pretransfer studies by receiving radiologists introduces several concerns regarding resource utilization, medicolegal risk, and technical quality control. The authors review the current status of transfer patient imaging, with an emphasis on the role of the receiving emergency radiologist. Practice solutions developed at the authors' level I trauma center are described.
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Affiliation(s)
- Michael F McNeeley
- Department of Radiology, University of Washington, Harborview Medical Center, Seattle, Washington 98195, USA.
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McNeeley MF, Prabhu SJ, Monroe EJ, Iyer RS. The nature and scope of moonlighting by radiology trainees. Acad Radiol 2013; 20:249-54. [PMID: 22981344 DOI: 10.1016/j.acra.2012.08.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2012] [Revised: 07/28/2012] [Accepted: 08/01/2012] [Indexed: 12/31/2022]
Abstract
RATIONALE AND OBJECTIVES The practice of moonlighting by trainees is a longstanding controversy; however, the resident point of view remains distinctly underrepresented in the radiology literature. We report the resident perspective on the moonlighting practices of radiology trainees. METHODS Survey data were collected from resident members of the Association of University Radiologists representing 84 training programs in the United States to assess their routine and extracurricular clinical responsibilities. Descriptive statistics were used to analyze these data. RESULTS Moonlighting is practiced by radiology trainees at nearly three-fourths of the programs represented in this survey. Interpreting diagnostic imaging (85.5%) and monitoring contrast administrations (72.6%) are the most common duties performed. Twenty-one percent of moonlighting trainees perform procedures (excluding diagnostic fluoroscopy) in their extracurricular positions; of these, most (61.5%) are without attending supervision. Most trainees that moonlight spend 1 to 10 hours weekly doing so while averaging a 59-hour workweek at their primary jobs. CONCLUSIONS The clinical duties of moonlighting trainees may be more diverse than has been previously recognized. Although major discrepancies between overnight radiology trainee interpretations and attending final interpretations have been shown to be infrequent, the consequences of trainees performing procedures and monitoring adverse contrast reactions without attending supervision are unknown. The financial and professional benefits of moonlighting must be weighed against the potential for harm. Our data suggest that most moonlighting radiology trainees operate within the Accreditation Council for Graduate Medical Education-mandated 80-hour weekly work limit; the mandatory 8-hour break between shifts and 24-hour continuous duty limit may pose logistical challenges.
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Affiliation(s)
- Michael F McNeeley
- Department of Radiology, University of Washington, Seattle Children's Hospital, 1959 Pacific Ave NE, Box 357115, Seattle, WA 98195, USA.
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Application of the RADPEER™ scoring language to interpretation discrepancies between diagnostic radiology residents and faculty radiologists. J Am Coll Radiol 2012; 9:264-9. [PMID: 22469377 DOI: 10.1016/j.jacr.2011.11.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Accepted: 11/17/2011] [Indexed: 11/20/2022]
Abstract
PURPOSE The objectives of this study were to assess the rate of discrepancies between radiology residents and faculty radiologists at an academic hospital using the RADPEER(™) scoring language and to determine if a correlation existed between assigned RADPEER score (2, 3, or 4) and the clinical significance of the error. METHODS Over 19 months, preliminary resident interpretations were graded using the RADPEER scoring system. A retrospective review of discrepant cases was performed to assess the percentage of discrepancy, change in clinical management, and identification of error patterns. RESULTS Of 2,255 preliminary interpretations, 29 discrepancies (1.29%) were judged to be potentially clinically significant. Of these, 14 (0.62%) resulted in immediate changes in clinical management. Discrepancies assigned RADPEER scores of 3 or 4 were significantly more likely to be judged clinically significant than those assigned scores of 2 (54.5% of 33 studies graded 3 or 4 and 7.7% of 142 studies graded 2, P < .0001). CT imaging generated a higher percentage of discrepancies that were predicted to be clinically significant than plain-film radiography, as well as a higher percentage of discrepancies that resulted in immediate changes in management, but the incidence of each remained low overall (≤2.1%). CONCLUSIONS Discrepancy rates in this study are comparable with previously reported data for discrepancies between attending radiologists and those between attending radiologists and residents data. A significant correlation was observed between increasing RADPEER scores and the clinical significance of discrepancies. This study supports the use of the RADPEER scoring language as both a resident quality assurance measure and an educational tool for quality improvement.
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Hohmann J, de Villiers P, Urigo C, Sarpi D, Newerla C, Brookes J. Quality assessment of out sourced after-hours computed tomography teleradiology reports in a Central London University Hospital. Eur J Radiol 2012; 81:e875-9. [PMID: 22608063 DOI: 10.1016/j.ejrad.2012.04.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2011] [Revised: 04/15/2012] [Accepted: 04/19/2012] [Indexed: 10/28/2022]
Abstract
The study was designed to assess the quality of out sourced after-hours computed tomography teleradiology service reports. We evaluated 1028 patients over a time period of five month in 2009/2010 (437 female, 591 male, mean age: 51 years, range: 0-97 years) who were referred either by the A&E or other in house departments from 7 pm to 8 am for different reasons. Reporting was done by a teleradiology service provider located in the UK and Australia. Reports were assessed during the routinely performed morning meeting by a panel of in house radiologists. Assessment was done by a five point agreement scale (5="No disagreement", 1="…unequivocal potential for serious morbidity or threat to life"). In 811 (79%) patients no disagreement was found, 164 (16%) were rated as category 4, 40 (4%) as category 3 ("…likelihood of harm is low"). In 13 (1.3%) patients a decision of category 2 was made ("…strong likelihood of moderate morbidity but not threat to life"). No category 1 decision was made. As this was just a discrepancy decision, a follow up of the category 2 patients was done over a period of a maximum of 6 months. In 8 (0.8%) patients the in house reports were correct, in 2 (0.2%) patients the teleradiology service provider was right and in 3 (0.3%) patients the final diagnoses remained unclear. In conclusion there was a small rate (0.8%) of proven serious misinterpretations by the teleradiology service provider, but these were less than in comparable studies with preliminary in house staff reports (1.6-24.6%).
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Affiliation(s)
- Joachim Hohmann
- Imaging Department, University College Hospital, University College London Hospitals, University College London, 235 Euston Road, London NW1 2BU, UK.
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Robinson JD, McNeeley MF. Transfer patient imaging: a survey of members of the American Society of Emergency Radiology. Emerg Radiol 2012; 19:447-54. [PMID: 22527362 DOI: 10.1007/s10140-012-1047-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Accepted: 04/11/2012] [Indexed: 11/30/2022]
Affiliation(s)
- Jeffrey D Robinson
- Department of Radiology, University of Washington, 325 9th Avenue, Box 359728, Seattle, WA 98104, USA.
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Berlin L. Quality Assurance and nighthawk Radiology. AJR Am J Roentgenol 2011; 197:W963-W963. [DOI: 10.2214/ajr.10.5532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Leonard Berlin
- NorthShore University HealthSystem, Skokie Hospital, Skokie, IL; Rush Medical College, Chicago, IL
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Ruma J, Klein KA, Chong S, Wesolowski J, Kazerooni EA, Ellis JH, Myles JD. Cross-Sectional Examination Interpretation Discrepancies Between On-Call Diagnostic Radiology Residents and Subspecialty Faculty Radiologists: Analysis by Imaging Modality and Subspecialty. J Am Coll Radiol 2011; 8:409-14. [DOI: 10.1016/j.jacr.2011.01.012] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2010] [Accepted: 01/27/2011] [Indexed: 10/18/2022]
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Xiong L, Trout AT, Bailey JE, Brown RK, Kelly AM. Comparison of Discrepancy Rates in Resident and Faculty Interpretations of On-Call PE CT and V/Q Scans: Is One Study More Reliable During Off Hours? J Am Coll Radiol 2011; 8:415-21. [DOI: 10.1016/j.jacr.2010.12.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2010] [Accepted: 12/10/2010] [Indexed: 11/27/2022]
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Effect of work hours, caseload, shift type, and experience on resident call performance. Acad Radiol 2010; 17:921-7. [PMID: 20540912 DOI: 10.1016/j.acra.2010.03.006] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2009] [Revised: 03/03/2010] [Accepted: 03/07/2010] [Indexed: 11/19/2022]
Abstract
RATIONALE AND OBJECTIVES To analyze the independent effects of multiple variables on resident call performance. MATERIALS AND METHODS Independent radiology resident "on call" cross-sectional imaging interpretation quality assurance (QA) data obtained during a 171-day period at a single tertiary care Level 1 trauma teaching institution was reviewed. Clinically significant resident-faculty discrepancies were compared among three different call types: traditional single-day overnight call (OC, 15 hours/night after 9 daytime hours on weekdays), 7-night nightfloat (NF, 9 hours/night), and weekend day call (WD, 10 hours/day). Logistic regression analyses were performed to evaluate associations. RESULTS There were 119 (0.89%) clinically significant resident-faculty discordances from 13,424 cross-sectional interpretations: 56 (0.79%) from 7102 interpretations on 172 OC shifts, 39 (0.85%) from 4567 interpretations on 165 NF shifts, and 24 (1.4%) from 1755 interpretations on 49 WD shifts. Individual residents (n = 20) had a mean discrepancy rate of 0.9% (0.45%-1.9%). Overall, 102 (26.2%) of the shifts had at least one discordance. The following were associated with significantly (P < .001) increased discrepancy rates: junior vs. senior residents (odds ratio [OR] = 1.3 [1.2-1.4]), OC vs. NF (OR = 1.5 [1.3-1.6], WD vs. NF (OR = 1.4 [1.2-1.6]), weekend vs. weekday (OR = 1.3 [1.2-1.4]), and increasing cases/hour (OR = 1.6 [1.5-1.7]). Weekend OC shifts had a higher discrepancy rate (OR 1.3[1.2-1.5], P < .001) than weekday OC shifts despite a shorter workday (15 vs. 24 hours). CONCLUSION Increasing caseload, junior residents, and weekends are associated with a significantly higher discrepancy rate. OC is associated with a significantly higher discrepancy rate than NF. Measured discrepancy rates are low, regardless of call type.
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Affiliation(s)
- Elcin Zan
- The Russell H. Morgan Department of Radiology and Radiological Sciences, the Johns Hopkins Medical Institutions, 600 N Wolfe St, Phipps B-112, Baltimore, MD 21287, USA
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Chung JH, Strigel RM, Chew AR, Albrecht E, Gunn ML. Overnight resident interpretation of torso CT at a level 1 trauma center an analysis and review of the literature. Acad Radiol 2009; 16:1155-60. [PMID: 19481962 DOI: 10.1016/j.acra.2009.02.017] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2009] [Revised: 02/26/2009] [Accepted: 02/27/2009] [Indexed: 10/20/2022]
Abstract
RATIONALE AND OBJECTIVES At the authors' level 1 trauma center, postgraduate year 3 and 4 radiology residents interpret urgent overnight imaging studies, which are reviewed by attending radiologists the next morning. The goals of this study were to determine the discrepancy rate for torso computed tomography between resident radiologists' preliminary interpretations and attending radiologists' final interpretations and to identify adverse patient events secondary to the delayed diagnoses. MATERIALS AND METHODS All torso computed tomographic studies interpreted by weekday night residents (8 pm to 8 am) from January 1, 2005, to March 13, 2007, were evaluated retrospectively. Major discrepancies between the residents' interpretations and the attending radiologists' interpretations were compiled. Exams with major discrepancies were additionally reviewed by two radiology residents and an attending emergency radiologist. The medical records of patients with major discrepant findings were also reviewed to identify adverse events that occurred because of the delays in final interpretation. RESULTS A total of 4768 chest, abdominal, and/or pelvic computed tomographic studies were interpreted during the study period. A total of 112 major discrepancies were collected. In 17 cases (15%), two additional radiology residents and an attending emergency radiologist agreed with the initial residents' interpretations, decreasing the major discrepancy rate to 95 of 4768 (2.0%), consistent with data from the literature (0.4%-10%). Management was changed in 16 patients (0.3%) because of the major discrepancies: 13 patients underwent additional investigations, and 3 patients were recalled to the emergency room. No mortality or morbidity was directly attributed to the delays in diagnosis. CONCLUSION At the authors' institution, there was a 2.0% discrepancy rate between residents' preliminary interpretations and attending radiologists' final interpretations of overnight torso computed tomography, with a small rate of additional intervention as a result of the major discrepancies. No adverse patient effects were directly attributable to discrepant interpretations. In discrepant cases, there was a 15% disagreement rate (17 of 112) between attending radiologists, suggesting some degree of interreader variance in interpretation. In addition, this disagreement rate among attending radiologists may imply that these cases were complex. Because there is educational value in overnight call, independent radiology resident coverage should continue.
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The DePICTORS Study: discrepancies in preliminary interpretation of CT scans between on-call residents and staff. Emerg Radiol 2009; 16:303-8. [DOI: 10.1007/s10140-009-0795-9] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2008] [Accepted: 01/14/2009] [Indexed: 11/26/2022]
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Chertoff J. Competency assessment in resident education. Acad Radiol 2008; 15:1215-6. [PMID: 18790391 DOI: 10.1016/j.acra.2008.07.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2008] [Revised: 07/01/2008] [Accepted: 07/07/2008] [Indexed: 11/19/2022]
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