Emergency department image interpretation accuracy: The influence of immediate reporting by radiology

To describe the diagnostic errors occurring in a busy district general hospital accident and emergency (A&E) department over four years. All diagnostic errors discovered by or notified to one A&E consultant were noted on a computerised database. 953 diagnostic errors were noted in 934 patients. Altogether 79.7% were missed fractures. The most common reasons for error were misreading radiographs (77.8%) and failure to perform radiography (13.4%). The majority of errors were made by SHOs. Twenty two diagnostic errors resulted in complaints and legal actions and three patients who had a diagnostic error made, later died. Good clinical skills are essential. Most abnormalities missed on radiograph were not difficult to diagnose. Junior doctors in A&E should receive specific training and be tested on their ability to interpret radiographs correctly before being allowed to work unsupervised.

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.

We aimed to assess the care and outcome of patients with minor injuries who were managed by a nurse practitioner or a junior doctor in our accident and emergency department. 1453 eligible patients, over age 16 years, who presented at our department with minor injuries were randomly assigned care by a nurse practitioner (n=704) or by a junior doctor (n=749). Each patient was first assessed by the nurse practitioner or junior doctor who did a clinical assessment; the assessments were transcribed afterwards to maintain masked conditions. Patients were then assessed by an experienced accident and emergency physician (research registrar) who completed a research assessment, but took no part in the clinical management of the patient. A standard form was used to compare the clinical assessment of the nurse practitioner or junior doctor with the assessment of the research registrar. The primary outcome measure was the adequacy of care (history taking, examination of patient, interpretation of radiographs, treatment decision, advice, and follow-up). Compared with the rigorous standard of the experienced accident and emergency research registrar, nurse practitioners and junior doctors made clinically important errors in 65 (9.2%) of 704 patients and in 80 (10.7%) of 749 patients, respectively. This difference was not significant. The nurse practitioners were better than junior doctors at recording medical history and fewer patients seen by a nurse practitioner had to seek unplanned follow-up advice about their injury. There were no significant differences between nurse practitioners and junior doctors in the accuracy of examination, adequacy of treatment, planned follow-up, or requests for radiography. Interpretation of radiographs was similar in the two groups. Properly trained accident and emergency nurse practitioners, who work within agreed guidelines can provide care for patients with minor injuries that is equal or in some ways better than that provided by junior doctors.