Possible solution for the problem of unread image interpretation reports: the “Gunma University Star Search”

• Published in: Japanese journal of radiology Vol. 38; no. 7; pp. 643 - 648
• Main Authors: Tsushima, Yoshito, Hirasawa, Hiromi, Wakabayashi, Yu, Taketomi-Takahashi, Ayako, Sutou, Takayuki, Tanaka, Kazumi, Takizawa, Makiko, Komatsu, Yasuhiro
• Format: Journal Article
• Language: English
• Published: Singapore Springer Singapore 01-07-2020; Springer Nature B.V
• Subjects: Communication; Diagnostic Errors - prevention & control; Double stars; Emergencies; Emergency medical services; Errors; Humans; Imaging; Japan; Magnetic resonance imaging; Medical errors; Medical materials; Medical referrals; Medicine; Medicine & Public Health; Nuclear Medicine; Original Article; Patient safety; Physicians; Quality Improvement; Radiology; Radiology - standards; Radiology Department, Hospital - standards; Radiology Information Systems - standards; Radiotherapy; Referral and Consultation; Retrospective Studies; Strategy; Telephone; Triple stars; Ultrasonic imaging; Japan; Radiology report; Communication error; Medical error
• ISSN: 1867-1071; 1867-108X
• DOI: 10.1007/s11604-020-00944-2

Purpose
To propose a new strategy to prevent communication errors caused by unread radiology reports.
Materials and methods
Medical emergencies were prefixed with triple stars on radiology reports, and the attending physician was contacted by telephone. Semi-emergencies (medical issues needing addressing within 2 weeks) were prefixed with double stars. Two weeks later, the duty radiologist would search the double-starred reports, and reviewed relevant patient charts to confirm that the information had been appropriately understood and acted upon. If not, the duty radiologist contacted the referral physician by telephone. One year after implementing this strategy, we retrospectively evaluated 1-year worth of data for all the reports of CT, MRI, nuclear medicine and ultrasonography (April 2018 to March 2019).
Results
Three hundred and twenty-one reports were double starred (0.52% of 62,143 reports, 1.32 reports/day), and transmission of relevant information was incomplete in 23 cases (7.17%). Causes of incomplete transmission were (1) reports not being opened (
n
 = 17), (2) relevant information on reports being overlooked (
n
 = 5), and (3) the wrong report being opened (
n
 = 1). Sixty-five reports contained triple stars (0.10%, 0.27 reports/day).
Conclusion
The proposed strategy may be effective in preventing communication errors in radiology reports with important findings requiring semi-emergency clinical action.