Management-changing errors in the recall of radiologic results - a pilot study

Abstract

Aim: To evaluate the occurrence of alterations to diagnostic information from radiological studies, which are altered by person-to-person communication and/or faulty recall, and whether they affect patient management

Materials and methods: A structured telephone survey was conducted at a large tertiary care medical centre of house staff managing inpatients who had undergone chest, abdominal, or pelvic computed tomography (CT) or magnetic resonance imaging (MRI) and remained in the hospital at least 2 days later. Fifty-six physicians were surveyed regarding 98 patient cases. Each physician was asked how he or she first became aware of the results of the study. Each was then asked to recall the substance of radiological interpretation and to compare it with the radiology report. Each was then asked to assess the level of difference between the interpretations and whether management was affected. Results were correlated with the route by which interviewees became aware of the report, the report length, and whether the managing service was medical or surgical.

Results: In nearly 15% (14/98) of cases, differences between the recalled and official results were such that patient management could have been (11.2%) or had already been affected (3.1%). There was no significant correlation between errors and either the route of report communication or the report length.

Conclusion: There was a substantial rate of error in the recall and/or transmission of diagnostic radiological information, which was sufficiently severe to affect patient management.