Discrepancies in Reporting the Vertebral Level of Abnormality in MR of the Spine

Introduction 

The National Quality Forum, a US public and private entity, issued results in 1999 indicating that between 44,000 and 98,000 Americans die each year from preventable medical errors in hospitals alone [1]. This issue was revisited again in 2008, when a list of 28 “never events” (errors that should not occur in medical practice) was proposed. These never events included surgery at the wrong site, surgery performed on the wrong patient, the wrong surgical procedure on the right patient, and patient death or serious disability associated with a medication error [2]. Various factors contribute to wrong-site surgeries, including the failure of surgeons to adopt guidelines and suggestions by authorities. In 2007, Jhawar et al [3] described the frequently reported factors for wrong-sided cranial surgery. These included emergency operating conditions, fatigue, and time pressures to begin or complete procedures.

To avoid wrong-site procedures, the Joint Commission [4] recommended that every patient undergo a preprocedural verification process to ensure that all relevant documents, related information, and equipment are available before the start of a procedure. The site of the procedure should be marked by a licensed independent practitioner. Also, to conduct a final assessment, surgeons and interventionalists should conduct a “time out” before beginning a procedure. This is to ensure that the correct patient, site, positioning, and procedure are identified.

To the best of our knowledge, no prior studies have assessed the frequency of errors in vertebral level in radiology reports.

The purpose of our study was to examine the frequency and severity of discrepancies in the spinal levels of abnormalities stated in the findings and impression (or both) sections of spinal magnetic resonance (MR) imaging reports at a tertiary care institution.

Materials and Methods 

This cross-sectional retrospective study was approved by the human research committee of our institution. The requirement for informed consent from study subjects was waived. This study was compliant with the Health Insurance Portability and Accountability Act. To protect the privacy of the reporting radiologists, our human research committee did not permit us to document the names of the radiologists who dictated the reports assessed in our study.

Radiology Reports With Identified Errors 

We queried all radiology reports from January 2006 through December 2007 (n = 2,097,966) using the radiology search engine with the key word MR spine. A total of 23,212 spinal MR reports were found (n = 11,427 in 2006, 6,099 in female and 5,328 in male patients; n = 11,785 in 2007, 6,366 in female and 5,419 in male patients). On these spinal MR reports, we applied the key word addendum, to identify spinal MR reports with addenda (n = 445 in 2006, 252 in female and 193 in male patients; n = 340 in 2007, 202 in female and 138 in male patients). The addended spinal MR reports were manually searched for discrepancies in the intervertebral levels of abnormalities described in the body and impression sections. Corresponding MR images for these studies were reviewed to confirm the recognized errors (Figure 1).

View Large Image Download to PowerPoint

Fig 1. Flowchart showing the search for erroneous radiology reports. MR = magnetic resonance; MRI = magnetic resonance imaging.

Results 

Radiology Reports With Identified Discrepancies 

Of the 23,212 spinal MR studies performed from January 1, 2006, through December 31, 2007, 11 reports (0.05%) had identified discrepancies in the vertebral levels of abnormalities between the body and impression sections (Figure 2). In 2006, there were 7 of 11,427 (4 in women, 3 in men; mean age, 61 years; age range, 34-77 years) reports with identified discrepancies in vertebral levels of the lesion. In 2007, there were 4 of 11,785 (3 in women, 1 in a man; mean age, 50 years; age range, 26-67 years) reports with identified discrepancies in the vertebral levels of abnormalities in the body and impression sections (Table 1). The average time taken to issue an addendum for correcting these discrepancies was 5 ± 1 days in 2006 and 14 ± 13 days in 2007.

View Large Image Download to PowerPoint

Fig 2. Flowchart depicting the incidence of errors (identified and unidentified) in the studied cohort. MR = magnetic resonance.

Table 1. Distribution of identified and corrected errors pertaining to the levels of vertebral abnormalities in spinal magnetic resonance reports (2006-2007)

	Gender⁎	Diagnosis of Error	Level of Abnormality Mentioned in the Body of the Report	Level of Abnormality Mentioned in the Impression of the Report	True Level of the Abnormality
	M	Spinal cord volume loss	T5/T6	Cervical(C5/C6)	T5/T6
	F	Disc herniation	C4/C5	Notmentioned	C5/C6
	F	Bony destruction	T3	L3	T3
	F	Endplate fracture	C6	C6	T6
	F	Progressed degenerative disease	T7/T8	T8/T9	T7/T8
	M	Postoperative laminectomies	L3,L4,L5	L3,L4,L5	T3,T4,T5
	M	Conus medullaris infarct and multilevel degenerative changes	Cervical	Cervical	Thoracic
	M	Epidural abscess	C6/C7	C6/C7	C5/C6
	F	Disc protrusion	C6/C7	C7/T1	C6/C7
	F	Metastatic soft tissue mass	L5	T1	L5
	F	Fractures and intervertebral disc injury	C6/C7	C6/C7	C7/T1

⁎ Seven female patients, 4 male patients.

Radiology Reports With Unidentified Errors 

In January 2006 and January 2007, unidentified discrepancies in the levels of vertebral abnormalities in spinal MR reports were noted in 8 of 828 reports (6 in women, 2 in men; mean age, 52 ± 12 years; age range, 38-77 years) and 12 of 952 reports (8 in women, 4 in men; mean age, 52 ± 17 years; age range, 31-76 years), respectively (Table 2). Thus, in January 2006 and January 2007, there were of 1.1% (20 of 1,780) unidentified errors in spinal MR reports (Figure 2).

Table 2. Distribution of unidentified errors pertaining to levels of vertebral abnormalities in spinal magnetic resonance reports (January 2006 and January 2007)

	Gender⁎	Diagnosis of Error	Level of Abnormality Mentioned in the Body of the Report	Level of Abnormality Mentioned in the Impression of the Report	True Level of the Abnormality
	F	Disc bulge	C3/C4	T3/T4	C3/C4
	F	Post laminectomy	L3/L4	L4/L5	L3/L4
	F	Post hemilaminectomy	L5/S1	L4/L5	L4/L5
	M	Post traumatic injury	C4/C5	T4/T5	C4/C5
	F	Endplate edema	L2/L3	L1/L2	L2/L3
	F	Nerve compression	S1	L5	L5
	M	Vertebral body expanded	T9	T8	T9
	F	Compression fracture	T3	T2	T3
	F	Inflammatory changes	S1	L1	S1
	M	Disc osteophyte	C3/C4	C5/C6	C5/C6
	M	Endplate edema	C3/C4	C2/C3	C3/C4
	F	Vertebral body height loss	T12	T9	T12
	M	Post diskectomy	C6/C7	C5/C6	C6/C7
	F	Canal stenosis	L2/L3	L2/T3	L2/L3
	F	Degenerative changes	T6/T7	C6/C7	T6/T7
	F	Tarlov cyst	S1/S2	S2/S3	S1/S2
	F	Vertebral hemangioma	L3	T3	L3
	F	Disc herniation	L3/L4	L2/L3	L3/L4
	M	Nerve compression	L1	S1	S1
	F	Soft tissue density	L2/S1	L5/S1	L5/S1

⁎ Fourteen women, 6 men.

Fortunately, none of the patients with unidentified errors had subsequent procedures or surgeries on the wrong vertebral levels. However, one patient did undergo an invasive procedure at the correct level, subsequent to imaging interpretation with an unidentified error. Also, in 4 of 20 reports with discrepant vertebral levels of abnormalities, the discrepancies were identified and corrected in subsequent reports or medical notes. The remaining patients with unidentified discrepancies did not have any addenda to original radiology reports or identification of errors in subsequent clinical notes (mean follow-up duration, 12-36 months).

Discussion 

Errors in medical practice have significant adverse effects on patient care. According to a report from the Institute of Medicine, a federal agency, medical errors result in more deaths than motor vehicle accidents, breast cancer, or acquired immune deficiency syndrome [6]. Wrong-sided or wrong-site surgery is one of the most common and significant medical errors.

In a recent study on the basis of a self-reported survey of Canadian neurosurgeons, the frequency of surgery at the wrong vertebral level is common. In fact, the incidence of cervical discectomy at the wrong level is about 6.8 per 10,000 surgeries [3]. The investigators noted that for spinal surgery, unusual patient anatomy and mistakes in radiographic reporting are common contributors to spinal surgeries at erroneous levels. However, to the best of our knowledge, there are no prior data on the incidence of incorrect assignment of vertebral levels of abnormalities in radiology reports.

Our study found discrepancies between the vertebral levels of abnormalities stated in the body and impression sections of radiology reports. Most discrepancies were not identified and corrected by the radiologists (unidentified errors, 20 of 1,780 [1.1%]), although some were subsequently corrected (11 of 23,212 [0.05%]) to state the correct vertebral levels of abnormalities. Unfortunately, for most radiology reports with discrepant vertebral levels of abnormalities in our study, the wrong levels were stated in the impression sections (21 of 31 [68%]), whereas the body sections correctly stated the vertebral levels with abnormalities.

Almost half (15 of 31 [48%]) of these discrepant reports on vertebral levels of abnormalities were clinically significant, and the time interval between the correction of a discrepant report and its initial dictation could be long (between 5 and 11 days). We were unable to compare these results with other published studies on radiology errors because, to the best of our knowledge, there are no similar studies reported in the indexed MEDLINE literature. We also observed that unidentified or uncorrected errors in vertebral levels of abnormalities were twice as frequent in female patients as in male patients (14 vs 6). This finding may have simply been related to the fact that more female patients underwent MR of the spine in both 2006 and 2007. It is interesting that a recent study on the prevalence of laterality errors (right vs left) in radiology reports also documented a greater number of errors in radiology reports for female patients compared with male patients [7].

Discrepancies noted in our study could have resulted from several factors, including busy MR services and reporting practices in our department, the presence of complex multilevel vertebral abnormalities, anatomic variability or artifacts affecting vertebral level count, human error in consistent counting of the vertebral level of abnormalities, or radiologists' reliance on memory when dictating the impression at the end of the reports. It is also possible that these errors were due to the use of voice recognition software; at other radiology centers, they may occur because of errors in transcription. Such errors constitute another reason for radiologists to validate report content, consistency, and concordance before final signature. Although these specific reasons were not assessed in our study, we believe that more than one of these factors may have contributed to the discrepancies observed in our study.

Another limitation of our study was the lack of an analysis of the distribution of the discrepant vertebral levels of abnormalities among individual radiologists, an aspect that our human research committee explicitly prohibited us from investigating. For similar reasons, we did not assess the reasons some of the discrepant reports were corrected and others remained unidentified. A major limitation of our study was that we did not assess errors in radiology reports compared with the actual MR images for which both the body and impression sections of reports stated the incorrect levels of abnormalities in the spine. Our study also did not estimate basic interpretative mistakes of the radiologists, which could have further increased the number of unidentified errors considerably. Thus, the prevalence of errors in stating vertebral levels of abnormalities in our study likely underestimated the actual magnitude of these errors.

Despite these limitations, our study has implications for both radiologists and referring physicians and surgeons. For referring physicians, we stress the importance of reading the entire radiology report instead of just the impression section. This is particularly important for surgeons or interventionalists who plan to undertake invasive procedures on the basis of MR reports. Radiologists must realize that discrepancies and errors in stating the correct vertebral level of abnormalities are frequent. They should make conscious efforts to match the vertebral levels reported in the impression and body sections of radiology reports before signing off the reports to referring physicians. Another option would be to “copy” and “paste” the body vertebral levels from the body section to the impression section.

We also propose that the ACR look into the issue of discrepancies in radiology reports and perhaps make exceptions to its two-part radiology report structures for spinal MR reports, so that these reports have only one section that identifies the vertebral levels of abnormalities. Annotation of MR images for vertebral levels of abnormalities may also help reduce these errors. Efforts of the Joint Commission to reduce medical errors are noteworthy to avoid erroneous site and side of surgery. Recently, the Joint Commission [4] introduced a universal protocol for image guided and invasive surgical procedures. This document describes guidelines to be adopted before and during procedures to prevent or minimize the incidence of wrong-side and wrong-site procedures. The introduction of similar practices for radiologists may also help avoid or reduce the prevalence of these discrepancies in radiology reports.

In conclusion, errors in the levels of lesions on spinal MR do occur in radiology reports. The number of unidentified errors is substantially higher than that of identified errors. Care should be taken before signing off on radiology reports to identify erroneous mentions of vertebral levels of abnormalities.