“Is That Your Final Answer?”- An Audit of Provisional versus Final Reports of On-Call CT Imaging

Audit to ensure the on-call CT reporting service provided by junior registrars has an acceptable discrepancy rate.

At many institutions, the on-call CT reporting service is provided by a two-tier rota, consisting of a specialist trainee (ST) with indirect supervision and an on-call Consultant. The ST is responsible for taking all referrals for imaging, with advice available from the senior colleague. Provisional reports are issued at the time of scanning, unless the ST is sufficiently experienced and a final report issued later when reviewed by senior colleague. Where discrepancies between reports are identified the referring team needs to be contacted, to allow for changes in clinical management.

The aim of this audit is to ensure a high standard of accuracy is provided by the STs.

The standard: 

There is no defined standard of discrepancy rates, for CT or for other imaging modalities. The literature from centres which have conducted similar audits demonstrate discrepancy rates of between 2.6-5.4%. A UK study of accuracy of acute abdominal CT published by the Royal College audit committee in 2017 reported a major discrepancy rate by STs of 4.6% compared with 3.1% for consultants.

Target: 

Local target:

- 5% for major discrepancies

- 10% for minor discrepancies

Indicators: 

- No. of discrepancies

- Total no. of scans performed out of hours

Data items to be collected: 

The ST collects perhaps 50 or 100 consecutive provisional reports and these are compared with the corresponding final report issued obtained from the Radiology Information System (RIS) retrospectively

These are reviewed for differences in interpretation.

The possible discrepancies are then reviewed with a consultant and categorised as significant or non-significant, depending on the potential impact on patient management. It may be helpful to categorise discrepancies

If a certain patient undergoes multiple examinations, each examination should be treated individually.

Suggested number: 

The number of scans and reports in this audit is dependent on the intensity of out-of-hours work.

• Subgroup analysis of which particular CT examination types, if any, have higher discrepancy rates that will help to target training or supervision, to improve reporting accuracy.

• A period of consultant-led supervision during an on-call period itself to ensure on-the-job training can allow real-time rectification of potential reporting errors. A repeat of the audit cycle can then be performed to assess the effectiveness of this strategy, perhaps focussing on examination types highlighted as more problematic at the first audit.

• More accurate documentation of the provisional report may also be introduced with voice recognition reporting that enables a provisional report to be placed on record and therefore a more accurate comparison with the final report, for audit purposes.

• It is important also that if discussion of a case occurs with the on-call Consultant that this is documented within the report.

ST to collect and review all on-call reports issued and correlate them with the final report. Review of discrepancies with consultant. For practical purposes it is suggested that this audit is done prospectively with copies of provisional reports kept.

1. The Royal College of Radiologists. Standards for Radiology Discrepancy Meetings. London: The Royal College of Radiologists, BFCR (14) 11 https://www.rcr.ac.uk/sites/default/files/docs/radiology/pdf/BFCR%2814%2911_LDMs.pdf

2. Team Working with Clinical Imaging: A Contemporary View of Skill Mix. Joint Guidance from the Royal College of Radiologists and the Society and College of Radiographers. London: The Royal College of Radiologists, January 2007.

3. The Royal College of Radiologists. Standards for Self-Assessment of Performance. London: The Royal College of Radiologists, September 2007.

4. Preliminary Interpretations of After-Hours CT and Sonography by Radiology Residents Versus Final Interpretations by Body Imaging Radiologists at a Level 1 Trauma Center. Carney E, Kempf J, DeCarvalho V, Yudd A, Nosher J. AJR, 2003; 181: 367-373.

5. Preliminary Radiology Resident Interpretations versus Attending Radiologist Interpretations and the Impact on Paient Care in a Community Hospital. Ruchman RB, Jaegerz J, Wiggins EF, Seinfeld S, Thakral V, Bollas S, Wallachs, S. AJR, 2007; 189: 523-526

6. Fool me twice: delayed diagnoses in radiology with emphasis on perpetuated errors.Kim YW1, Mansfield LT. AJR Am J Roentgenol. 2014 Mar;202(3):465-70. doi: 10.2214/AJR.13.11493. https://www.ncbi.nlm.nih.gov/pubmed/24555582

7. Howlett DC, Drinkwater K, Frost C, Higginson A, Ball C & Maskell G. The accuracy of interpretation of emergency abdominal CT in adult patients who present with non-traumatic abdominal pain: results of a UK national audit. Clinical Radiology 72 (2017) 41-51.http://dx.doi.org/10.1016/j.crad.2016.10.008

A Nair, H Verma, A Parthipun, S Negus, Rewritten by P Malcolm