REGULAR CONTENT
Final ID
540
Type
Original Scientific Research-Oral or Pos
Authors
K Shah1, M Dayan1, A Aboff1, V Gendel1, J Kempf1
Institutions
1Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ
Purpose
Interventional Radiology (IR) reports serve a critical role in communicating imaging and interventional procedures as well as procedural outcomes to the referring physician. At times it may be necessary to provide additional information or clarification to an original report, referred to as an addendum. Although our IR dictations use structured reporting, addenda creation is an unstructured method performed for a variety of reasons. The purpose of this presentation is to determine the frequency for IR addendum reporting at our institution and identify the most common causes of addendum creation and potential impact on patient care, along with potential methods to decrease addenda in future reporting.
Materials & Methods
We performed a retrospective review of all body IR report addenda performed over a two year period at our level I trauma center/tertiary care hospital from Jan 1, 2014-December 31, 2015. There were a total of 19,568 IR body procedures reviewed. We identified and categorized the common causes of addenda and classified each with regards to potential minor versus major impact on patient care.
Results
There were 79 report addenda of 19,568 IR body reports over the reviewed period for a frequency of 0.4%. The mean time difference from the original report and the addendum was 71.8 hours. The most common causes of addenda was the addition of missing procedural details (30.4%) including missing or incorrect fluoroscopy or sedation times. Additional causes for addenda included procedure correction such as correcting the type or size of catheters (22.8%), as well as errors related to structured reporting (11.4%). The majority of addenda had minor or no effect on patient care. 12.7% of the addenda had major impact on patient care, defined as potential to cause harm.
Conclusions
We found a low frequency of 0.4% of body IR addended reports. The most common reason for an addendum was to add a missing step in a procedure. Structured reporting has created a new category of addenda. 87.3% of the addenda had a minor impact on patient care. Suggestions to decrease the number of created addenda are to add more open fields to structured reports and a checklist to templates to ensure a step is not forgotten.
Final ID
540
Type
Original Scientific Research-Oral or Pos
Authors
K Shah1, M Dayan1, A Aboff1, V Gendel1, J Kempf1
Institutions
1Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ
Purpose
Interventional Radiology (IR) reports serve a critical role in communicating imaging and interventional procedures as well as procedural outcomes to the referring physician. At times it may be necessary to provide additional information or clarification to an original report, referred to as an addendum. Although our IR dictations use structured reporting, addenda creation is an unstructured method performed for a variety of reasons. The purpose of this presentation is to determine the frequency for IR addendum reporting at our institution and identify the most common causes of addendum creation and potential impact on patient care, along with potential methods to decrease addenda in future reporting.
Materials & Methods
We performed a retrospective review of all body IR report addenda performed over a two year period at our level I trauma center/tertiary care hospital from Jan 1, 2014-December 31, 2015. There were a total of 19,568 IR body procedures reviewed. We identified and categorized the common causes of addenda and classified each with regards to potential minor versus major impact on patient care.
Results
There were 79 report addenda of 19,568 IR body reports over the reviewed period for a frequency of 0.4%. The mean time difference from the original report and the addendum was 71.8 hours. The most common causes of addenda was the addition of missing procedural details (30.4%) including missing or incorrect fluoroscopy or sedation times. Additional causes for addenda included procedure correction such as correcting the type or size of catheters (22.8%), as well as errors related to structured reporting (11.4%). The majority of addenda had minor or no effect on patient care. 12.7% of the addenda had major impact on patient care, defined as potential to cause harm.
Conclusions
We found a low frequency of 0.4% of body IR addended reports. The most common reason for an addendum was to add a missing step in a procedure. Structured reporting has created a new category of addenda. 87.3% of the addenda had a minor impact on patient care. Suggestions to decrease the number of created addenda are to add more open fields to structured reports and a checklist to templates to ensure a step is not forgotten.