An analysis of radiographer preliminary image evaluation – A focus on common false negatives

Abstract

Introduction: Preliminary image evaluation (PIE) is a mechanism whereby radiographers provide a preliminary evaluation of whether pathology is present in their radiographs, typically acquired within the emergency department (ED). PIE provides referrers with a timely communication of pathology prior to the availability of a radiology report. The purpose of this study was to determine the most common radiographer PIE false-negative interpretations. Methods: Each month over a two-year period, 100 PIEs of adult and paediatric patients were randomly reviewed in a metropolitan hospital ED. The radiographer's PIE was compared with the radiologist's report and categorised into basic quality indicators; true positive, true negative, false positive and false negative. The anatomical regions which most commonly indicated a false-negative interpretation were further analysed. Results: 2402 cases were reviewed which resulted in an overall PIE accuracy of 88.7%. Wrists, hands, phalanges (upper), ankles, feet and phalanges (lower) reporting the highest false-negative or falsenegative/true-positive interpretations (60/116). Of the 60 false-negative PIEs, 68 pathologies were identified. 41.1% (28/68) of the pathology not identified were in the phalanges. Within these regions, examinations with multiple injuries commonly reported false negatives (17/60). Conclusions: This study demonstrated the most common false-negative radiographer PIEs were within the upper and lower distal extremities. Specifically, the phalanges and examinations demonstrating multiple injuries reported high levels of misinterpretation. The misinterpretation in multi-injury examinations could be attributed to 'Subsequent Search Miss (SSM)' error. These results provide valuable insights into areas of emphasis when providing image interpretation education.

The role of quality improvement in radiography

“…These two significant studies 1,2 included in this issue clearly signal the right direction for radiographers in using quantitative and qualitative research to improve the overall quality of our profession. Quality improvement in the ED is important as this is an area where we can be working to full scope of practice and provide accurate image interpretation to guide clinical and treatment decisions (i.e.…”

“…This issue of the Journal of Medical Radiation Sciences (JMRS) features two interesting articles which performed retrospective quality improvement studies on digital radiography in an Australian metropolitan emergency department (ED). The first study (Alexander-Bates et al) 1 involved the investigation of a radiographer preliminary image evaluation (PIE) system, highlighting the most common false-negative interpretations by crosscorrelation of the radiographer's evaluation of any suspected pathology on x-ray with the radiologist's report. Their study used a clinical audit to assess the quality improvement on PIE accuracy within their ED and identified that most of the false-negative radiographer PIEs were within upper and lower distal extremities.…”

“…4 As addressed by the authors, projection-specific reject and multiple reject analysis is important for QI to reduce patient radiation exposure. 2 Alexander-Bates' et al 1 study is also recognised as a long-term QA study due to their large monthly sample size (n = 100) deemed adequate for a local clinical audit according to the Royal College of Radiologists. 5 Both studies examined two important aspects of medical imaging -PIE and reject analysis, which are critical for improving the quality of everyday services and patient care.…”

“…There is an assumption that the audit will improve practice in the longer term, but this can only be demonstrated by follow-up research using the advice to educate and monitor changes from the respective authors of these two studies. 1,2 Alexander-Bates et al 1 and Stephenson et al 2 are both QA studies which focus on human error that seek to identify and reduce outliers or poor performance as a method. QA is an activity that is part of QI, which is required to establish an advanced confidence that performance is maintained at a high standard.…”

“…As this study suggests, 'education would allow radiographers to communicate "urgent and unexpected findings" to referrers, assisting in the treatment of patients and reducing missed pathology'. 1 This issue of JMRS also includes a study by Galli et al 8 which involved an image quality review programme for mammography based on the 2006 European guidelines for QA in breast cancer screening and diagnosis. Interestingly, this longitudinal study did follow a CQI model where training and monitoring of entry-level and experienced radiographers developed the mammogram service and improved technical assessments of image quality.…”