title: 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.
authors.affiliation: Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue ML 5031, Cincinnati, OH, 45229, USA.
authors.forename: C Matthew
authors.initials: CM
authors.lastname: Hawkins
authors.forename: Seth
authors.initials: S
authors.lastname: Hall
authors.forename: Bin
authors.initials: B
authors.lastname: Zhang
authors.forename: Alexander J
authors.initials: AJ
authors.lastname: Towbin
mesh_terms: D006801:Humans; D016347:Medical Records Systems, Computerized / Q000458:organization & administration / Q000592:standards*; D011871:Radiology / Q000379:methods / Q000592:standards*; D011872:Radiology Department, Hospital / Q000458:organization & administration / Q000592:standards*; D011873:Radiology Information Systems / Q000592:standards*; D015203:Reproducibility of Results; D049250:Speech Recognition Software / Q000592:standards*