Abdominal Imaging Interpretive Errors in a Quality Assurance Database: One Institution's Experience Over a 5-Year Period.

OBJECTIVES

We hypothesized that interpretive error location and patient harm are significantly associated in a quality assurance database.

METHODS

We reviewed all interpretive errors reported in the abdomen and pelvis in a quality assurance database over a 5-year period. Imaging exam data, interpretive error, anatomic location, and clinical outcome by the Agency for Healthcare Research and Quality Harm Scale were recorded. Multivariable logistic regression modeling was performed.

RESULTS

263 interpretive error reports were identified. The most reported error locations included hepatobiliary (15%), gastrointestinal tract (13%), bone (13%), reproductive organs (12%), and peritoneum/mesentery/omentum (12%). Of the 263, 165 (63%) errors were found to result in any patient harm, compared with 98/263 (37%) errors with no harm. Anatomic category was significantly associated with harm when adjusted for age, sex, exam setting, and exam priority in our logistic regression model ( P =0.003). When compared with hepatobiliary errors, errors in the kidney/ureter/bladder, gastrointestinal tract, and reproductive organs were associated with greater odds of harm. Errors in the peritoneum/mesentery/omentum and bone were associated with smaller odds of harm. Retroperitoneum/body wall and vascular errors had similar odds of harm to hepatobiliary errors.

CONCLUSION

Interpretive error location is significantly associated with patient harm. Our results may inform an evidence-based approach toward improving the process by which errors are reviewed in radiology quality assurance programs. The most reported interpretive error locations in an abdominal imaging quality assurance system are not necessarily the most harmful to patients.