On-Call Radiology Resident Discrepancies: Categorization by Patient Location and Severity

PurposeTo report discrepancy rates for examinations interpreted by on-call residents overall and by resident training level, and to describe a novel discrepancy classification system based on patient location and severity that facilitates recording of discrepancy data, helps ensure proper communication of report changes, and allows our radiology department to assume responsibility for contacting discharged patients with non-time-dependent results.MethodsA HIPAA-compliant, institutional review board–exempt review of two years (January 2013 to December 2014) of discrepancy data was retrospectively performed for total number of examination interpreted, discrepancy rates, resident training level, and discrepancy categories. Most common diagnoses and means of results communication for discharged patients were also recorded.ResultsRadiology residents interpreted 153,420 examinations after hours and had 2169 discrepancies, for an overall discrepancy rate of 1.4%. Discrepancy rates for postgraduate year (PGY)-3, PGY-4, and PGY-5 residents were 1.31%, 1.65%, and 1.88%, respectively. The rate of critical discrepancies was extremely low (10/153,420 or 0.007%). A total of 502 patients (23.2% of all discrepancies) were discharged at the time their discrepancy was identified, 60% of whom had non-time-dependent discrepancies that were communicated by radiologists; 32.4% of these had addended results telephoned to a PCP, 43.4% had addended results telephoned to the patient, and the remaining 24.2% required a registered letter. Eight percent of patients with non-time-dependent findings were lost to follow-up.ConclusionsOur resident discrepancy rates were comparable to those published previously, with extremely low rates of critical discrepancies. Radiologists assumed responsibility for contacting the majority of discharged patients with discrepant results, a minority of whom were lost to follow-up.     

“Concordance” Revisited: A Multispecialty Appraisal of “Concordant” Preliminary Abdominopelvic CT Reports

PurposeTo determine whether resident abdominopelvic CT reports considered prospectively concordant with the final interpretation are also considered concordant by other blinded specialists and abdominal radiologists.MethodsIn this institutional review board–approved retrospective cohort study, 119 randomly selected urgent abdominopelvic CT examinations with a resident preliminary report deemed prospectively “concordant” by the signing faculty were identified. Nine blinded specialists from Emergency Medicine, Internal Medicine, and Abdominal Radiology reviewed the preliminary and final reports and scored the preliminary report with respect to urgent findings as follows: 1.) concordant; 2.) discordant with minor differences; 3.) discordant with major differences that do not alter patient management; or 4.) discordant with major differences that do alter patient management. Predicted management resulting from scores of 4 was recorded. Consensus was defined as majority agreement within a specialty. Consensus major discrepancy rates (ie, scores 3 or 4) were compared to the original major discrepancy rate of 0% (0/119) using the McNemar test.ResultsConsensus scores of 4 were assigned in 18% (21/119, P < .001, Emergency Medicine), 5% (6/119, P = .03, Internal Medicine), and 13% (16/119, P < .001, Abdominal Radiology) of examinations. Consensus scores of 3 or 4 were assigned in 31% (37/119, P < .001, Emergency Medicine), 14% (17/119, P < .001, Internal Medicine), and 18% (22/119, P < .001, Abdominal Radiology). Predicted management alterations included hospital status (0-4%), medical therapy (1%-4%), imaging (1%-10%), subspecialty consultation (3%-13%), nonsurgical procedure (3%), operation (1%-3%), and other (0-3%).ConclusionsThe historical low major discrepancy rate for urgent findings between resident and faculty radiologists is likely underreported.     

Emergency imaging discrepancy rates at a level 1 trauma center: identifying the most common on-call resident “misses”

The focus of our research is to identify the most frequently reported on-call discrepancies at our hospital by modality and level of resident training. Our intent is to identify specific areas of concern that may be amenable to improvement through initiation of dedicated resident training in the field of emergency radiology. Our study included 648 significant discrepancies from 193,722 studies ordered through the emergency department over a 7-year period. The overall discrepancy rates were calculated for each resident level of training and modality type. Significance was determined using χ2 testing with α?=?0.05. The most common types of discrepancies were identified. The overall rate of reported discrepancies was low for all levels of training (0.23–0.42 %) with a small, but statistically significant, decrease in rate for the senior residents. Common categories of discrepancies for all residents included fractures on radiographs (XR) and computed tomography (CT), masses and hemorrhage on CT, and lung nodules and pulmonary infiltrates on radiographs. Specific discrepancies reported more frequently for new call-takers included phalangeal fractures on XR as well as white matter disease, hepatic lacerations, pyelonephritis, peritoneal fluid, lymphadenopathy, and pneumothoraces on CT. It is our recommendation that radiology resident training programs ensure that the common discrepancies illustrated herein are specifically addressed as part of a dedicated emergency radiology course.     

Evaluating the Impact of a Call Triage Assistant on Resident Efficiency,Errors, and Stress

ObjectiveThe aim of this study was to evaluate whether a call triage assistant, who answered telephone calls to the main reading room during the busiest hours of weekend call, would impact resident workflow efficiency, diagnostic errors, and stress level.MethodsThe call triage assistant answered all telephone calls to the main reading room from 12 pm to 7 pm on 6 weekend days over a 3-month period. We compared report turnaround times and resident discrepancy rates on these days with control days, when the same residents were on call without the assistant. We also surveyed residents to determine whether the assistants relieved anxiety associated with the call shift.ResultsWe recorded 168 telephone calls over the study period. We found the majority of telephone calls could be handled by the assistant without disturbing the on-call resident, resulting in a 71% reduction in interruptions. The mean turnaround time for studies read on the days the assistant was on duty was 44.3 min, compared with 75.2 min on the control days (P < .01). Resident major discrepancy rates (0.4% on the intervention days compared to 0.2% on the control days) were similar (P = .58), as were minor discrepancy rates (7.5% on the intervention days compared with 6.7% on the control days; P = .61). Residents reported fewer distractions, improved workflow efficiency, and decreased call-related stress when the assistant was on duty.ConclusionsA call triage assistant effectively improved workflow efficiency and reduced resident stress on call. Resident error rates were unaffected by the presence of the assistant.     

Discrepancies in Radiograph Interpretation Between Pediatric Radiologists and Pediatric Intensivists in the Pediatric or Neonatal Intensive Care Unit

BackgroundIn pediatric intensive care units (PICUs) and neonatal intensive care units (NICUs), patient management decisions are sometimes based on preliminary interpretations of radiographs by pediatric intensivists (PIs) before a formal interpretation by a pediatric radiologist (PR).ObjectiveTo quantify and classify discrepancies in radiographic interpretation between PRs and PIs in the PICU and NICU.Materials and MethodsThis institutional review board–approved multi-institutional prospective study included three PRs and PIs at two PICUs and three NICUs. Interpretations of chest and abdominal radiographs by PIs and PRs were recorded on online forms and compared. Discrepancies in interpretations were classified as “miss,” “misinterpretation,” or “overcall.” The discrepancies were also categorized as “actionable” or “nonactionable” based on extrapolation of the ACR actionable reporting work group’s list of actionable findings.ResultsIn 960 radiographic interpretations, the total, nonactionable, and actionable discrepancy rates between PRs and PIs were 34.7%, 26.8%, and 7.9%, respectively. The most common actionable discrepancies were line or tube positions and identification and interpretation of parenchymal opacities in the lungs. Identification of air leaks in the PICU and differentiation of normal from abnormal bowel gas patterns in the NICU followed in frequency. Air leaks accounted for 1% of total discrepancies and 11% of actionable discrepancies. Most discrepancies were nonactionable and included retrocardiac atelectasis and mischaracterization of neonatal lung disease in the PICU and NICU, respectively.ConclusionAlthough the total discrepancy rate was high, most discrepancies were nonactionable. Actionable discrepancies were predominantly due to line and tube position, which should be an area of focused education.     

Overnight shift work: factors contributing to diagnostic discrepancies

The aims of the study are to identify factors contributing to preliminary interpretive discrepancies on overnight radiology resident shifts and apply this data in the context of known literature to draw parallels to attending overnight shift work schedules. Residents in one university-based training program provided preliminary interpretations of 18,488 overnight (11 pm–8 am) studies at a level 1 trauma center between July 1, 2013 and December 31, 2014. As part of their normal workflow and feedback, attendings scored the reports as major discrepancy, minor discrepancy, agree, and agree—good job. We retrospectively obtained the preliminary interpretation scores for each study. Total relative value units (RVUs) per shift were calculated as an indicator of overnight workload. The dataset was supplemented with information on trainee level, number of consecutive nights on night float, hour, modality, and per-shift RVU. The data were analyzed with proportional logistic regression and Fisher’s exact test. There were 233 major discrepancies (1.26 %). Trainee level (senior vs. junior residents; 1.08 vs. 1.38 %; p?<?0.05) and modality were significantly associated with performance. Increased workload affected more junior residents’ performance, with R3 residents performing significantly worse on busier nights. Hour of the night was not significantly associated with performance, but there was a trend toward best performance at 2 am, with subsequent decreased accuracy throughout the remaining shift hours. Improved performance occurred after the first six night float shifts, presumably as residents acclimated to a night schedule. As overnight shift work schedules increase in popularity for residents and attendings, focused attention to factors impacting interpretative accuracy is warranted.     

First year radiology residents not taking call: will there be a difference?

Currently, there is a debate in the academic radiology community about whether or not first year residents should take overnight call. The purpose of this study was to track discrepancies on overnight resident preliminary reads on radiographs from the emergency department to see if the experience level of the resident makes a difference. From October 1, 2005 to September 22, 2006, 13,213 radiographs were prospectively interpreted by residents at night at a Level I Trauma Center. Discrepancies were documented after review of the films with the staff radiologist in the morning. The patient’s medical record was then examined to determine if there was any adverse clinical outcome as a result of the reading. Of the 13,184 radiographs interpreted, 120 total discrepancies were identified (overall discrepancy rate 0.9%). First year residents showed a discrepancy rate of 1.59%, higher than other residents, which were ranged from 0.39 to 0.56%. Of the 54 patients with follow-up imaging, the abnormality that was felt to be present by staff persisted on follow-up imaging in 22 cases; however, the abnormality was not present on follow up of the other 32 patients (59.2% of discrepancies with follow-up imaging). Although there is higher rate of discrepancy among reports generated by first year residents, the difference compared to the other levels of experience is small, and its overall significance can be debated. Follow-up imaging often showed that staff interpretations were false positives when there was a discrepancy reported.     

The DePICTORS Study: discrepancies in preliminary interpretation of CT scans between on-call residents and staff

At many academic hospitals, radiology residents provide preliminary interpretations of CT studies performed outside of regular working hours. We examined the rate of discrepancies between resident interpretations and final reports issued by staff. We prospectively obtained 1,756 preliminary reports and corresponding final reports for computed tomography (CT) scans performed on call between November 2006 and March 2007. The overall rate of clinically significant discrepancies (those that would potentially alter the patient’s clinical course prior to issue of the final report) was 2.0%. Major discrepancy rates for abdominal/pelvic, chest, cervical spine and head CT were 4.1%, 2.5%, 1.0% and 0.7%, respectively. Senior residents had fewer major discrepancies compared to their junior colleagues. Time of interpretation was also evaluated, but a statistically significant relationship was not observed. In summary, this study demonstrates a low discrepancy rate between residents and staff radiologists and identifies areas where after-hours service may be further improved.     

Ensuring Appropriateness of Pediatric Second Opinion Consultations

PurposeWe sought to evaluate discrepancy rates between outside interpretations, radiology trainee preliminary reports, and subspecialist attending final interpretations for pediatric second opinion consultations on plain film and computed tomography imaging and to evaluate the impact of a process improvement for second opinion consultations.MethodsOf a total of 572 requests for second opinion consultations during 1-year preintervention period, we utilized RADPEER to score concurrence of 158 requests which occurred overnight and included outside radiologist interpretations and resident preliminary reports. In consultation with clinician committees, we developed new guidelines for requesting second opinion consultations. We evaluated the impact on the number of consultations for the 1-year period following implementation of this process improvement.ResultsThere was concurrence between the outside interpretation and pediatric subspecialist second opinion in 146 of 158 cases (92%). There was concurrence between the radiology resident and pediatric subspecialist second opinion in 145 of 158 cases (92%). During the 1-year period following our process improvement implementation, the total number of second opinion consultations decreased to 185 (from 572, a decrease of 68%) and the number of overnight requests for resident preliminary reports decreased to 11 (from 158, a decrease of 93%).ConclusionsThere was a high degree of concurrence between interpretations provided by outside radiologists, overnight radiology residents, and attending pediatric radiologists at our institution. Analyzing institutional-specific discrepancy rates is a valuable first step in partnering with clinicians to develop appropriate guidelines for second opinion consultations.     

Comparing Preliminary and Final Neuroradiology Reports: What Factors Determine the Differences?

BACKGROUND AND PURPOSE:Trainees'' interpretations of neuroradiologic studies are finalized by faculty neuroradiologists. We aimed to identify the factors that determine the degree to which the preliminary reports are modified.MATERIALS AND METHODS:The character length of the preliminary and final reports and the percentage character change between the 2 reports were determined for neuroradiology reports composed during November 2012 to October 2013. Examination time, critical finding flag, missed critical finding flag, trainee level, faculty experience, imaging technique, and native-versus-non-native speaker status of the reader were collected. Multivariable linear regression models were used to evaluate the association between mean percentage character change and the various factors.RESULTS:Of 34,661 reports, 2322 (6.7%) were read by radiology residents year 1; 4429 (12.8%), by radiology residents year 2; 3663 (10.6%), by radiology residents year 3; 2249 (6.5%), by radiology residents year 4; and 21,998 (63.5%), by fellows. The overall mean percentage character change was 14.8% (range, 0%–701.8%; median, 6.6%). Mean percentage character change increased for a missed critical finding (+41.6%, P < .0001), critical finding flag (+1.8%, P < .001), MR imaging studies (+3.6%, P < .001), and non-native trainees (+4.2%, P = .018). Compared with radiology residents year 1, radiology residents year 2 (−5.4%, P = .002), radiology residents year 3 (−5.9%, P = .002), radiology residents year 4 (−8.2%, P < .001), and fellows (−8.7%; P < .001) had a decreased mean percentage character change. Senior faculty had a lower mean percentage character change (−6.88%, P < .001). Examination time and non-native faculty did not affect mean percentage character change.CONCLUSIONS:A missed critical finding, critical finding flag, MR imaging technique, trainee level, faculty experience level, and non-native-trainee status are associated with a higher degree of modification of a preliminary report. Understanding the factors that influence the extent of report revisions could improve the quality of report generation and trainee education.

Understanding the prevalence, causes, and types of discrepancies and errors in examination interpretation is a critical step in improving the quality of radiology reports. In an academic setting, discrepancies and errors can result from nonuniform training levels of residents and fellows. However, even the “experts” err, and a prior study found a 2.0% clinically significant discrepancy rate among academic neuroradiologists.¹ A number of factors can affect the accuracy of radiology reports. One variable of interest at teaching hospitals is the effect of the involvement of trainees on discrepancies in radiology reports. Researchers have found that compared with studies read by faculty alone, the rate of clinically significant detection or interpretation error was 26% higher when studies were initially reviewed by residents, and it was 8% lower when the studies were initially interpreted by fellows.² These findings suggest that perhaps faculty placed too much trust in resident interpretations, which led to a higher rate of discrepancies, while on the other hand, having a second experienced neuroradiology fellow look at a case can help in reducing the error rate.²In our academic setting, preliminary reports initially created by trainees are subsequently reviewed and finalized by faculty or staff. The changes made to preliminary reports are a valuable teaching tool for trainees because clear and accurate report writing is a critical skill for a radiologist.³ Recently, computer-based tools have been created to help trainees compare the changes between preliminary and final reports to improve their clinical skills and to facilitate their learning. Sharpe et al⁴ described the implementation of a Radiology Report Comparator, which allows trainees to view a merged preliminary/final report with all the insertions and deletions highlighted in “tracking” mode. Surrey et al⁵ proposed using the Levenshtein percentage or percentage character change (PCC) between preliminary and final reports as a quantitative method of indirectly assessing the quality of preliminary reports and trainee performance. The Levenshtein percentage, a metric used in computer science, compares 2 texts by calculating the total number of single-character changes between the 2 documents, divided by the total character count in the final text.⁵In this study, we analyzed preliminary neuroradiology reports dictated by trainees and the subsequent finalized reports revised by our faculty. We set out to identify the factors that determine the degree to which the preliminary reports are modified by faculty for residents and fellows, for daytime and nighttime shifts, and for CT and MR imaging examinations. We hypothesized that study complexity, lack of experience (for both trainee and faculty), and perhaps limited language skills (native-versus-non-native speaker) would result in a greater number of corrections.     

Comparison of on-call radiology resident and faculty interpretation of 4- and 16-row multidetector CT pulmonary angiography with indirect CT venography

RATIONALE AND OBJECTIVES: On-call radiology residents frequently interpret computed tomography (CT) pulmonary angiography and CT venography studies outside of routine working hours. The purpose of this study was to compare resident and faculty interpretation concordance rates and to see if concordance rates differed depending on the number of CT detectors used. MATERIALS AND METHODS: The study population included 122 consecutive CT pulmonary angiography (CTPA) and CT venography (CTV) examinations performed on a four-row multidetector CT (MDCT) and 125 consecutive CTPA examinations performed using a 16-row MDCT scanner with CTV performed in 124 patients. Preliminary resident reports and final faculty reports were compared. Discrepant cases were independently reviewed by three cardiothoracic radiologists who were unaware of the initial interpretations. Interpretation concordance rates were calculated for both 4- and 16- row MDCT studies and compared using Fisher's exact test. RESULTS: Resident and faculty CTPA and CTV interpretations were concordant in 80% of the 4-row cases and 94% of the 16-row cases. When comparing resident interpretation to the final expert reference standard, the corrected resident error rate was 11% and 2% for 4-row CTPA and CTV, respectively and 4% and 2% for 16-row CTPA and CTV, respectively. Overall CTPA and CTV concordance was significantly lower for 4-row MDCT (80% versus 94%, P < .001 [two-sided] by Fisher's exact test). CONCLUSIONS: Radiology resident interpretation of CTPA and CTV studies demonstrates a high level of agreement with radiology faculty interpretation. Concordance rates are significantly higher for 16-row MDCT than 4-row MDCT which may be due to improved image quality.     

Emergency abdominal radiography: Discrepancies of preliminary and final interpretation and management relevance

The purpose of this study was to determine the discrepancy rate between the preliminary interpretation of abdominal radiographs by emergency physicians compared to the final report rendered by gastrointestinal radiologists, and to assess the impact of such discrepancies on patient management. A retrospective analysis was performed on a sample of abdominal plain radiographs obtained in the emergency department of a private urban teaching hospital. Written preliminary interpretations by the emergency physician were compared to the final dictated reports of the gastrointestinal radiologist. An emergency physician determined whether availability of the final interpretation would have changed patient management. There were 387 abdominal plain film studies that satisfied the criteria for inclusion. Of these, 98 discordant interpretations were noted (an interpretive discrepancy rate of 25.3%). In 16 of the 98 cases (16%), the interpretive discrepancy was deemed to have resulted in a difference in patient management, i.e., a management-relevant discrepancy rate of 4.1% of the total study population. This analysis shows a higher interpretive discrepancy rate for emergency department interpretation of abdominal radiographs than has been reported with emergency department interpretations of other types of radiographs. The most common clinically relevant interpretive discrepancies were misinterpretation of intestinal obstruction and unrecognized urinary tract calculi. Presented at the 6th Annual Scientific Program, American Society of Emergency Radiology, Scottsdale, AZ, March 28, 1995.     

Computed tomography colonography: Radiographer independent preliminary clinical evaluation for intraluminal pathology

IntroductionWe evaluated the reporting competency of radiographers providing preliminary clinical evaluations (PCE) for intraluminal pathology of computed tomography colonography (CTC).MethodFollowing validation of a suitable tool, audit was undertaken to compare radiographer PCE against radiology reports. A database was designed to capture radiographer and radiologist report data. The radiographer's PCE of intraluminal pathology was given a score, the “pathology discrepancy and significance” (PDS) score based on the pathology present, any discrepancy between the PCE and the final report, and the significance of that discrepancy on the management of the patient. Agreement was assessed using percentage agreement and Kappa coefficient. Significant discrepancies between findings were compared against endoscopy and pathology reports.ResultsThere was agreement or insignificant discrepancy between the radiographer PCE and the radiology report for 1736 patients, representing 97.0% of cases. There was a significant discrepancy between findings in 2.8% of cases and a major discrepancy recorded for 0.2% of cases. There was a 98.4% agreement in the 229 cases where significant pathologies were present.ConclusionFrom a database of 1815 studies acquired over three years and representing work done in a clinical environment, this study indicates a potential for trained radiographers to provide a PCE of intraluminal pathology.     

Clinical Impact of Second Opinion Radiology Consultation for Patients With Breast Cancer

PurposeTo assess the incidence and clinical significance of discrepancy in subspecialty interpretation of outside breast imaging examinations for newly diagnosed breast cancer patients presenting to a tertiary cancer center.Materials and MethodsThis Institutional Review Board–approved retrospective study included patients presenting from July 2016 to March 2017 to a National Cancer Institute–designated comprehensive cancer center for second opinion after breast cancer diagnosis. Outside and second opinion radiology reports of 252 randomly selected patients were compared by two subspecialty breast radiologists to consensus. A peer review score was assigned, modeled after ACR’s RADPEER^TM peer review metric: 1—agree; 2—minor discrepancy (unlikely clinically significant); 3—moderate discrepancy (may be clinically significant); 4—major discrepancy (likely clinically significant). Among cases with clinically significant discrepancies, rates of clinical management change (management alterations including change in follow-up, neoadjuvant therapy use, and surgical management as a direct result of image review), and detection of additional malignancy were assessed through electronic medical record review.ResultsA significant difference in interpretation (scores = 3 or 4) was seen in 41 of 252 cases (16%, 95% confidence interval [CI], 11.7%-20.8%). The difference led to additional workup in 38 of 252 cases (15%, 95% CI 10.6%-19.5%) and change in clinical management in 18 of 252 cases (7.1%, 95% CI 4.0%-10.2%), including 15 of 252 with change in surgical management (6.0%, 95% CI, 3.0%-8.9%). An additional malignancy or larger area of disease was identified in 11 of 252 cases (4.4%, 95% CI, 1.8%-6.9%).ConclusionDiscrepancy between outside and second-opinion breast imaging subspecialists frequently results in additional workup for breast cancer patients, changes in treatment plan, and identification of new malignancies.     

Part I: preparing first-year radiology residents and assessing their readiness for on-call responsibilities

RATIONALE AND OBJECTIVES: The aim of the study is to evaluate the effectiveness of an Emergency Radiology (ER) Core Curriculum training module and a Digital Imaging and Communications in Medicine (DICOM)-based interactive examination system to prepare first-year (postgraduate year 2 [PGY-2]) radiology residents and assess their readiness for taking overnight radiology call. MATERIALS AND METHODS: Institutional review board approval was obtained, and the study was compliant with Health Insurance Portability and Accountability Act (HIPAA) regulations. A dedicated month-long ER curriculum was designed to prepare new radiology residents for overnight radiology call that includes interpretation of off-hour urgent and emergent studies without immediate direct attending supervision. Lectures of the curriculum, provided by department staff, were based on the American Society of Emergency Radiology core curriculum. The lecture series was implemented after PGY-2 residents had completed formal introductory resident rotations during their first 6 months of training. A DICOM-based interactive computer-based testing module was developed and administered at the end of the lecture series. The module consisted of 19 actual emergency department cases with entire series of images, simulating an on-call setting. Tests were scored by two staff members blinded to resident identifying information. Upper-level residents also were tested, and comparison was made between first-year and upper-level resident test scores to determine the effectiveness of the test in determining first-year resident preparedness for call. Statistical analysis of results was performed by using t-test (P < .05). RESULTS: All residents in the residency program present during the month (nine PGY-2, six PGY-3, seven PGY-4, seven PGY-5 residents) attended the lecture series and finished the testing module at the end of the lecture series. Of 19 actual emergency cases on the testing module, five cases were neuroradiology, three cases were thoracic imaging, eight cases were body imaging, and three cases were musculoskeletal. PGY-2 residents scored an average of 73.0% (range, 63.2%-81.6%) of total points possible. PGY-3 residents scored an average of 76.8% (range, 68.4%-86.8%); PGY-4 residents scored an average of 77.4% (range, 65.8%-100%), and PGY-5 residents scored an average of 81.2% (range, 68.4%-94.7%). There was no statistically significant difference in scores according to level of training. CONCLUSION: First-year radiology residents who underwent 6 months of formal radiology training followed by an intensive ER lecture series before taking overnight call had scores similar to upper-level colleagues on an interactive computer-based ER simulation module.     

Radiology resident interpretations of on-call imaging studies: the incidence of major discrepancies

RATIONALE AND OBJECTIVES: To determine the incidence of radiology resident preliminary interpretation errors for plain film, body computed tomography, and neuroradiology (neuro)computed tomographic examinations read on call. MATERIALS AND METHODS: We retrospectively reviewed the data in a prospectively acquired resident quality assurance (QA) database dating between January 2000 and March 2007. The database comprises all imaging studies initially interpreted by an on-call resident and later reviewed by a board-certified attending radiologist who determined the level of discrepancy between the two interpretations according to a graded scale from 0 (no discrepancy) to 3 (major discrepancy). We reviewed the data with respect to resident training level, imaging modality, and variance level. Statistical analysis was performed with chi(2) test, alpha = 0.05. We compared our results with other published series studying resident and attending accuracy. RESULTS: A total of 141,381 cases were entered into the database during the review period. Of all examinations, 95.7% had zero variance, 3.3% minor variance, and 1.0% major variance. There was a slight, statistically significant increase in overall accuracy with increased resident year from 95.4% of examinations read by first-year residents (R1s) to 96.1% by fourth-year resident (R4s) (P < .0001). Overall percentages of exams with major discrepancies were 1.0% for R1s, 1.1% for second-year residents, 1.0% for third-year residents, and 0.98% for R4s. CONCLUSIONS: The majority of preliminary resident interpretations are highly accurate. The incidence of major discrepancies is extremely low and similar, even with R1s, to that of attending radiologists published in other studies. A slight, statistically significant decrease in the error rate is detectable as residents gain experience throughout the 4 years of residency.     

Proctoring of New Emergency Radiologists to Promote Clinical Excellence and Ensure Quality of Care

PurposeThe authors’ institution provides 24/7 attending radiologist final interpretations for all emergency, urgent, and inpatient studies. As a supplement to the existing emergency radiology faculty, the institution relies on two groups of radiologists to provide final imaging interpretations after hours: radiology fellows (RFs) and newly hired subspecialty radiologists (NRs). For both groups, subspecialty services provide overreads the following day to improve the skills of the staff members and ensure clinical excellence. The purpose of this study was to compare the clinical significance and rate of discrepancies between RFs and NRs.MethodsA retrospective review of all overreads from July 1, 2012, to June 30, 2015, was performed. Discrepancy rates for RFs and NRs were calculated. Error significance for cases requiring addenda was categorized as follows: acute, likely malignant, indeterminate, unlikely to be of clinical significance, insignificant typographic error, or significant typographic error.ResultsIn total, 10,796 studies were rechecked, of which 1.9% (n = 205) required addenda, 3.6% (n = 384) were deemed addendum-optional, and 94.5% (n = 10,207) required no comments. There was no significant difference in cases requiring addenda (RFs, 1.7% [119 of 6,847]; NRs, 2.2% [86 of 3,949]; P = .11). Of the 205 cases requiring addenda, 21.0% (n = 43) were deemed to be acute, 4.9% (n = 10) likely malignant, 28.3% (n = 58) indeterminate, 32.7% (n = 67) unlikely to be of clinical significance, and 13.1% (n = 27) secondary to typographic errors (66.7% [n = 18] deemed to be significant).ConclusionsAfter-hours coverage with RFs and NRs allows high-quality final, actionable interpretations with low discrepancy rates and no significant difference between both groups for addendum-needed cases. The program strikes a balance between the need for timely interpretations and the need to continually monitor and improve the quality of interpretations through subspecialist feedback.     

Virtual reality-based simulation improves gynecologic brachytherapy proficiency,engagement, and trainee self-confidence

PURPOSEIntracavitary brachytherapy is critical in treatment of cervical cancer with the highest rates of local control and survival. Only about 50% of graduating residents express confidence to develop a brachytherapy practice with caseload as the greatest barrier. We hypothesize that virtual reality (VR)-based intracavitary brachytherapy simulation will improve resident confidence, engagement, and proficiency.METHODSWe created a VR training video of an intracavitary brachytherapy case performed by a board-certified gynecologic radiation oncologist and medical physicist. Residents performed a timed intracavitary procedure on a pelvic simulator before and after viewing the VR simulation module on a commercially available VR headset while five objective measures of implant quality were recorded. The residents completed a pre- and postsimulation questionnaire assessing self-confidence, procedural knowledge, and perceived usefulness of the session.RESULTSThere were 14 residents, including five postgraduate year (PGY)-2, three PGY-3, four PGY-4, and two PGY-5, who participated in the VR curriculum. There were improvements in resident confidence (1.43–3.36), and subjective technical skill in assembly (1.57–3.50) and insertion (1.64–3.21) after the simulation. Average time of implant decreased from 5:51 to 3:34 (p = 0.0016). Median technical proficiencies increased from 4/5 to 5/5. Overall, the residents found VR to be a useful learning tool and indicated increased willingness to perform the procedure again.CONCLUSIONSVR intracavitary brachytherapy simulation improves residents’ self-confidence, subjective and objective technical skills, and willingness to perform brachytherapy. Furthermore, VR is an immersive, engaging, time-efficient, inexpensive, and enjoyable tool that promotes residents interest in brachytherapy.     

Preliminary Radiology Report Discordances and Patient Outcomes

Rationale and ObjectivesAt 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 MethodsFor 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.ResultsOf 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.ConclusionAdverse 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.