Creation and Implementation of Department-Wide Structured Reports: An Analysis of the Impact on Error Rate in Radiology Reports

Abstract

The purpose of this study was to evaluate and compare textual error rates and subtypes in radiology reports before and after implementation of department-wide structured reports. Randomly selected radiology reports that were generated following the implementation of department-wide structured reports were evaluated for textual errors by two radiologists. For each report, the text was compared to the corresponding audio file. Errors in each report were tabulated and classified. Error rates were compared to results from a prior study performed prior to implementation of structured reports. Calculated error rates included the average number of errors per report, average number of nongrammatical errors per report, the percentage of reports with an error, and the percentage of reports with a nongrammatical error. Identical versions of voice-recognition software were used for both studies. A total of 644 radiology reports were randomly evaluated as part of this study. There was a statistically significant reduction in the percentage of reports with nongrammatical errors (33 to 26 %; p=0.024). The likelihood of at least one missense omission error (omission errors that changed the meaning of a phrase or sentence) occurring in a report was significantly reduced from 3.5 to 1.2 % (p=0.0175). A statistically significant reduction in the likelihood of at least one comission error (retained statements from a standardized report that contradict the dictated findings or impression) occurring in a report was also observed (3.9 to 0.8 %; p=0.0007). Carefully constructed structured reports can help to reduce certain error types in radiology reports.

A Default Normal Chest CT Structured Reporting Field for Coronary Calcifications Does Not Cause Excessive False-Negative Reporting

“…Structured radiology reporting promised to improve report quality as structures are described in a regular and predictable order and there is a decrease of missense-omission errors (words omitted from dictations which ultimately change the intended meaning) [11,9]. Indeed, a recent study has demonstrated that structured chest radiograph reports are more complete and effective than unstructured reports [10].…”

“…Indeed, a recent study has demonstrated that structured chest radiograph reports are more complete and effective than unstructured reports [10]. Furthermore, fields for entry of specific data within a structured report have the potential to direct radiologists' search patterns and facilitate consistent reporting of findings that would not otherwise have elicited specific comment if the radiologist was using free-style dictation [8,11,12,13]. Radiologists tasked with creation of standardized reports for an organization may incorporate the latest thinking on value-adding imaging data and suggest items for incorporation.…”

“…al. which noted that a default normal appendix statement led to “errors of commission” (an unnoticed template statement which results in internally contradictory statements within the final report) which necessitated changes in their template [11]. A possible explanation for the difference is that in our template there was a completely separate sentence for coronary calcifications, which was easily and consistently seen by users and removed if necessary.…”

Improving Radiology Report Quality by Rapidly Notifying Radiologist of Report Errors

“…Common dictation errors related to SR generated reports include, but are not limited to, wrong-word substitution, nonsensical phrases, and errors of omission [13][14][15][16]. Reports may also contain clinical errors that are not specific to the SR software.…”

Adding Value as Young Radiologists: Challenges and Opportunities, Part 1

“…In addition to patient care, these reports are commonly components of educational, research, legal, and billing purposes. The use of structured reporting has been shown to improve image interpretation and surgical planning compared with nonstructured reports [20][21][22]. However, multiple studies indicate that radiology report guidelines and templates insufficiently address clear objectives and implementation issues [18,19,23].…”