Revealing the most common reporting errors through data mining of the report proofreading process

Abstract

Objectives To investigate the most common errors in residents’ preliminary reports, if structured reporting impacts error types and frequencies, and to identify possible implications for resident education and patient safety. Material and methods Changes in report content were tracked by a report comparison tool on a word level and extracted for 78,625 radiology reports dictated from September 2017 to December 2018 in our department. Following data aggregation according to word stems and stratification by subspecialty (e.g., neuroradiology) and imaging modality, frequencies of additions/deletions were analyzed for findings and impression report section separately and compared between subgroups. Results Overall modifications per report averaged 4.1 words, with demonstrably higher amounts of changes for cross-sectional imaging (CT: 6.4; MRI: 6.7) than non-cross-sectional imaging (radiographs: 0.2; ultrasound: 2.8). The four most frequently changed words (right, left, one, and none) remained almost similar among all subgroups (range: 0.072–0.117 per report; once every 9–14 reports). Albeit representing only 0.02% of analyzed words, they accounted for up to 9.7% of all observed changes. Subspecialties solely using structured reporting had substantially lower change ratios in the findings report section (mean: 0.2 per report) compared with prose-style reporting subspecialties (mean: 2.0). Relative frequencies of the most changed words remained unchanged. Conclusion Residents’ most common reporting errors in all subspecialties and modalities are laterality discriminator confusions (left/right) and unnoticed descriptor misregistration by speech recognition (one/none). Structured reporting reduces overall error rates, but does not affect occurrence of the most common errors. Increased error awareness and measures improving report correctness and ensuring patient safety are required. Key Points • The two most common reporting errors in residents’ preliminary reports are laterality discriminator confusions (left/right) and unnoticed descriptor misregistration by speech recognition (one/none). • Structured reporting reduces the overall the error frequency in the findings report section by a factor of 10 (structured reporting: mean 0.2 per report; prose-style reporting: 2.0) but does not affect the occurrence of the two major errors. • Staff radiologist review behavior noticeably differs between radiology subspecialties.

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Turning radiology reports into epidemiological data to track seasonal pulmonary infections and the COVID-19 pandemic

“…One aspect that facilitated report labeling by means of a regular expression algorithm is the consistent use of structured reporting and standardized terminology in our department [ 31 – 33 ]. Our reports often include a negation statement regarding common diagnoses such as pulmonary infections.…”

Structured Reporting in Musculoskeletal Radiology

“…By using the checklist approach with uniform terminology, it can lead to more homogeneity of reporting, concise lexicon usage within and across practices, divisional and departmental branding, and future data mining. 1 In this new era with the push toward patientcentric care, structured reporting provides a way for the radiology community to serve not just patients and our busy referring clinicians with improved communications, but it also increases efficiency in a health care system facing a shortage of clinicians. 2,3 This article discusses the different kinds of report formats used by radiologists, their advantages and disadvantages, and the potential impact of each within the health care system.…”