A retrospective review of the abnormalities missed in plain film radiographs at Addenbrooke's Hospital's Emergency Department
Background: Plain film radiographs (X-rays) are a key investigative tool used by clinicians in the Emergency department (ED). It is standard practice that every X-ray ordered by the clinicians working within the ED is reviewed and reported by radiologists; on occasion discrepancies occur between the interpretation by the clinician and the radiologist. Addenbrooke's Hospital employs a safety-net whereby consultants check abnormal radiological reports and corroborate this with the patient's medical notes during a designated Admin, Trauma and Teaching (ATT) shift. This aims to ensure that any radiological finding identified by the radiologist that was missed during the initial assessment by clinicians is acted upon.
Aims: To analyse missed radiological abnormalities as recorded in the Microsoft Access database in order to identify the trends and clinical significance of these abnormalities to help develop relevant educational materials for staff. Furthermore, this study aimed to evaluate the use of this element of the safety net system by consultants and recommend changes to facilitate the logging of the missed findings.
Methods: This study was a retrospective review of a Microsoft Access database used to log abnormalities missed on X-rays in the ED at Addenbrooke’s Hospital between September 2015 and January 2018. The database recorded information regarding incidents of missed radiological abnormalities and the appropriate action instituted. Addenbrooke’s Hospital’s Electronic Patient Record System (EPICÒ) was used to gather information on the demographics of the patients. The Chi square test was used to compare the frequency of discrepancies.
Results: 96 incidents of missed radiological findings were identified in the database during the study period. This signifies a missed abnormality rate (as recorded by the database) of 0.49% (96/19493). Paediatric abnormalities were more commonly missed than those in any other age group. Abnormalities of the spine were found to be the most frequently overlooked, with a total discrepancy rate of 1.81% (6/332). The clinical consequences of the missed findings were variable with 36.5% (n=35) of the cases requiring ‘advice only’, 32.3% (n=31) were referred to the fracture clinic, and 18.8% (n=18) required a return visit to the ED. When examining the recording of data, a delay of 1.25 days occurred between the publishing of the radiological report and the identification of the missed abnormality. The entry of data was heavily dependent on the consultant completing the ATT shift, with an average of 0.21 abnormalities logged per shift.
Conclusion: The system in place for the review and recording of missed radiological abnormalities at Addenbrooke’s ED is a key safety process. The process of logging incidents should be made simpler to allow maintenance and internal auditing of this safety-net. The results show that there are certain anatomical regions which are associated with a higher number of missed abnormalities, as are paediatric injuries and thus care should be taken in interpretation of these X-rays.. Enhanced teaching in these areas is suggested.
