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      Radiologic discrepancies in diagnosis of fractures in a Dutch teaching emergency department: a retrospective analysis

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          Abstract

          Background

          Missed fractures in the emergency department (ED) are common and may lead to patient morbidity.

          Aim

          To determine the rate and nature of radiographic discrepancies between ED treating physicians, radiologists and trauma/orthopaedic surgeons and the clinical consequences of delayed diagnosis. A secondary outcome measurement is the timeframe in which most fractures were missed.

          Methods

          A single-centre retrospective analysis of all missed fractures in a general teaching hospital from 2012 to 2017 was performed. Data regarding missed fractures were provided by the hospital’s complication list and related database. Additional data were retrieved from the electronic medical records as required for the study.

          Results

          A total of 25,957 fractures were treated at our ED. Initially, 289 fractures were missed by ED treating physicians (1.1%). The most frequently missed fractures were the elbow (28.6%) and wrist (20.8%) in children, the foot (17.2%) in adults and the pelvis and hip (37.3%) in elderly patients. Patients required surgery in 9.3% of missed fractures, received immobilization by a cast or brace in 45.7%, had no treatment alterations during the first week in 38.1%. Follow-up data were lacking for 6.9% of cases. 49% of all missed fractures took place between 4 PM and 9 PM. There is a discrepancy in percentages of correctly diagnosed fractures and missed fractures between 5 PM and 3 AM.

          Conclusion

          Adequate training of ED treating physicians in radiographic interpretation is essential in order to increase diagnostic accuracy. A daily multidisciplinary radiology meeting is very effective in detecting missed fractures.

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          Most cited references17

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          Diagnostic errors in an accident and emergency department

          H Guly (2001)
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            Accuracy of radiographic readings in the emergency department.

            A review of radiology discrepancies of emergency department (ED) radiograph interpretations was undertaken to examine the types of error made by emergency physicians (EPs). An ED quality assurance database containing all radiology discrepancies between the EP and radiology from June 1996 to May 2005 was reviewed. The discrepancies were categorized as bone, chest (CXR), and abdomen (AXR) radiographs and examined to identify abnormalities missed by EPs. During the study period, the ED ordered approximately 151 693 radiographs. Of the total, 4605 studies were identified by radiology as having a total of 5308 abnormalities discordant from the EP interpretation. Three hundred fifty-nine of these abnormalities were not confirmed by the radiologist (false positive). The remainder of the discordant studies represented abnormalities identified by the radiologist and missed by the EP (false negatives). Of these false-negative studies, 1954 bone radiographs (2.4% of bone x-rays ordered) had missed findings with 2050 abnormalities; the most common missed findings were fractures and dislocations. Of the 220 AXRs (3.7% of AXRs ordered) with missed findings, 240 abnormalities were missed; the most common of these was bowel obstruction. Of the 2431 CXRs (3.8% of CXRs ordered), 2659 abnormalities were missed; the most common were air-space disease and pulmonary nodules. The rate of discrepancies potentially needing emergent change in management based solely on a radiographic discrepancy was 85 of 151 693 x-rays (0.056%). Approximately 3% of radiographs interpreted by EPs are subsequently given a discrepant interpretation by the radiology attending. The most commonly missed findings included fractures, dislocations, air-space disease, and pulmonary nodules. Continuing education should focus on these areas to attempt to further reduce this error rate. Copyright © 2011 Elsevier Inc. All rights reserved.
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              Errors in fracture diagnoses in the emergency department – characteristics of patients and diurnal variation

              Background Evaluation of the circumstances related to errors in diagnosis of fractures at an Emergency Department may suggest ways to reduce the incidence of such errors. Methods Retrospective analysis of all cases during a two year period (2002–2004) where a fracture had been overlooked or an injury had been erroneously diagnosed as a fracture (n = 61). 100 random selected patients with correctly diagnosed fractures served as control group. Results In the two year period 5879 patients visited the ED with injuries. 1% of all visits to the ED resulted in an error in fracture diagnosis and 3.1% of all fractures were not diagnosed at the initial visit to the ED. 86% of such errors had consequences for treatment. No patient characteristics could be identified as risk factors for a misdiagnosis of a fracture. There was a peak in errors in fracture diagnoses between 8 pm and 2 am (47% against 20% in controls, p < 0.005). Conclusion A considerable number of fractures were not correctly diagnosed at the initial ED visit. There was a diurnal variation in the rate of misdiagnosis of fractures with a significant peak from 8 pm to 2 am. Where there was an error in fracture diagnosis, the patients did not appear to have a characteristic profile as regarding e.g. age, sex or capability to communicate with the ED staff. Increased consultancy service in radiology may reduce the frequency of errors in diagnosis, particularly in the evenings between 8 pm and 2 am.
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                Author and article information

                Contributors
                laurahorstink@gmail.com
                judithlangeraar@gmail.com
                gert-janmauritz@hotmail.com
                w.stappen@cwz.nl
                maartenbaggelaar@hotmail.com
                Edward.tan@radboudumc.nl
                Journal
                Scand J Trauma Resusc Emerg Med
                Scand J Trauma Resusc Emerg Med
                Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine
                BioMed Central (London )
                1757-7241
                13 May 2020
                13 May 2020
                2020
                : 28
                : 38
                Affiliations
                [1 ]Department of Emergency Medicine, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
                [2 ]GRID grid.415930.a, Department of Emergency Medicine, Rijnstate, ; Arnhem, The Netherlands
                [3 ]Department of Surgery, Canisius-Wilhelmina Ziekenhuis, Nijmegen, the Netherlands
                [4 ]Department of Emergency Medicine, Canisius-Wilhelmina Ziekenhuis, Nijmegen, The Netherlands
                [5 ]Department of Surgery, Radboudumc, Nijmegen, The Netherlands
                [6 ]Department of Emergency Medicine, Radboudumc, Nijmegen, The Netherlands
                Author information
                http://orcid.org/0000-0002-0188-3365
                Article
                727
                10.1186/s13049-020-00727-8
                7222339
                32404206
                0070731d-b88d-4c2d-bd92-fa03af5ae7a3
                © The Author(s) 2020

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

                History
                : 16 September 2019
                : 17 April 2020
                Categories
                Original Research
                Custom metadata
                © The Author(s) 2020

                Emergency medicine & Trauma
                emergency department,fracture,radiographs,radiologic discrepancies,missed diagnosis,diagnostic error

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