Critical issues in radiology requests and reports
Tóm tắt
This study evaluated the appropriateness and accuracy of 500 radiology requests and their matched reports in order to identify recurring errors in both areas. A randomly chosen sample consisting of 167 computed tomography (CT), 166 ultrasonography (US) and 167 radiographic examinations were collected and analysed according to national referral guidelines and to the principles of justification and optimisation (Law no. 187/2000). We identified a high rate of inappropriate requests (27.6%) and requests lacking a clinical question (22%). There was good precision in the anamnestic data (80.6%) and in the formulation of the diagnostic question (76.8%). Almost all requests were handwritten, and 12.5% lacked the referring physician’s stamp and/or signature. No report mentioned the clinical information received or the equipment used. The use of contrast medium was always reported. Conclusions were reported in 9.8% of these reports. When further investigation would have been necessary, the radiologist omitted to report this in 60% of cases. Some important weaknesses emerged, especially regarding requests for radiological examinations (22% lacked the clinical question, 27.6% were inappropriate), potentially limiting the effectiveness of the diagnostic process and leading to negative effects on the correct risk management process. There emerges a need for better collaboration between clinicians and radiologists.
Tài liệu tham khảo
Tamburrini O, Dalla Palma F (2007) L’Atto Medico Radiologico. Il Radiologo 3(Suppl 3):3S–15S
Schiavon F, Berletti R (2006) Il radiologo e la refertazione. Suggerimenti per una corretta comunicazione. Edizioni Minerva Medica, Torino
Linee guida Nazionali di riferimento in diagnostica per immagini (2004) Agenzia per i Servizi Sanitari Regionali. Tipografia Marchesini, Roma
Coakley FV, Liberman L, Panicek DM (2003) Style guidelines for radiology reporting: a manner of speaking. AJR Am J Roentgenol 180:327–328
Ferris MH (2000) Opinion: language of the radiology report: primer for residents and wayward radiologist AJR Am J Roentgenol 175:1239–1242
Fileni A, Magnavita N (2006) A 12-year follow-up study of malpractice claims against radiologist in Italy. Radiol Med 111:1009–1022
Fileni A, Magnavita N, Mammi F et al (2007) Malpractice stress syndrome in radiologists and radiotherapists: perceived causes and consequences. Radiol Med 112:1069–1084
Centro Studi Ministero della Sanità (2001) Relazione della Commissione per lo studio delle problematiche dei Servizi di Diagnostica per Immagini. ASI n. 28
Berlin L (1997) Malpractice issues in radiology: radiology reports. AJR Am J Roentgenol 169:943–946
Berlin L (2000) Malpractice issues in radiology: pitfalls of the vague radiology report. AJR Am J Roentgenol 174:1511–1518
Magnavita N, Fileni A, Magnavita G et al (2008) Work stress in radiologist. A pilot study. Radiol Med 113:329–346