Overnight resident preliminary interpretations on CT Examinations: should the process continue?

Abstract

We report our experience with resident preliminary interpretations given at night on both abdominal and neurological CT scans to quantify the discrepancy rate when compared to the final report. An attempt was also made to document any adverse clinical outcomes as a result of the preliminary interpretation. From January 1, 2004 to December 31, 2004, adult CT examinations were prospectively interpreted by residents at night at a level I trauma center. Both the neurological and body CT scans were reviewed beginning at 7:00 a.m. the following morning by the respective subspecialty staff and discrepancies were noted. Adult CT examinations (6,858) were prospectively interpreted by residents: 5,206 cranial spinal CT examinations and 1,652 body CT examinations. Among the neurological studies, there were six cases identified as major discrepancies (0.1%) and 185 minor discrepancies (3.5%). Among the body CT cases, there were seven cases identified as major discrepancies (0.4%) and 23 cases of minor discrepancies (1.4%). There is a low discrepancy rate (0.2% major and 3.1% minor) in the preliminary resident interpretations from the final report. The process of overnight preliminary CT interpretations should continue as it is not substandard care.

Trainee Misinterpretations on Pediatric Neuroimaging Studies: Classification, Imaging Analysis, and Outcome Assessment

“…This is an important finding in our study that differs from that in previous studies based primarily on the adult population. Although misinterpretation of brain attenuation has been described as a cause of major discrepancies in some adult studies, 8 those cases were typically the result of focal stroke or vasogenic edema, rather than diffuse brain insult as in our study. Findings of diffuse brain edema can be subtle, 13,14 and misidentification may result in inadequate or delayed treatment.…”

“…In our method, discrepancy classification as major (type 1) or minor was based on the potential immediate clinical impact of the misinterpretation. 8 Type 1 (major, life-threatening) discrepancies were defined as those in which the findings were of major clinical importance and the knowledge of which could result in immediate therapeutic plan alterations. These could include (but were not restricted to) the following: subdural or epidural hemorrhage Ͼ2 mm in maximum thickness, intraparenchymal hemorrhage Ͼ5 mm in greatest dimension, any ICH demonstrating mass effect, diffuse edema with signs of increased intracranial pressure, acute hydrocephalus with signs of increased intracranial pressure, missed mass lesion (with significant mass effect or secondary hydrocephalus), nontraumatic subarachnoid hemorrhage, and missed signs of large arterial distribution infarct.…”

Overnight Preliminary Head CT Interpretations Provided by Residents: Locations of Misidentified Intracranial Hemorrhage

“…The significance of these findings can be debated because we did not observe a single adverse clinical outcome resulting from the discrepancies, but we acknowledge that a discrepancy in 1 case alone could have a horrific outcome for a patient. 4 Opponents of overnight head CT interpretation by residents do not acknowledge the inherent error rate in interpretation by board-certified radiologists and that the residents' readings are ultimately compared with the attendings' readings, which have been shown to be an imperfect clinical standard. 12 With a more complete understanding of misinterpretation of intracranial hemorrhage by residents, their education can be tailored to help decrease its frequency in the future and ultimately help improve patient care.…”

“…[4][5][6][7] Erly et al 7 described the experience with 1324 residents' preliminary interpretations on head CT examinations and found a 2% major discrepancy rate and a 7% minor discrepancy rate. Major discrepancies included vasogenic edema misinterpreted as ischemia, a missed suprasellar mass, acute infarcts, and contusion.…”

“…[1][2][3] An argument for providing continuous in-house attending coverage is the presence of errors in preliminary interpretation of examinations by residents; however, the error rate for overnight preliminary interpretations by residents has been shown to be quite low. [4][5][6][7][8] CT examination of the head is the most frequently requested after-hours study and can account for up to 57% of all CT examinations performed on call. 9 The fear of being unable to detect intracranial hemorrhage among radiology residents at our institution was the impetus for our study.…”