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

Purpose

The aim of this study was to assess discrepancies in the spinal levels of abnormalities stated in the findings or impression (or both) sections of radiology reports of magnetic resonance (MR) imaging.

Materials and Methods

Radiology reports from January 2006 through December 2007 (n = 2,097,966) were analyzed using an online radiology report search engine. Reports were searched for presence of the key words MR spine and addendum. The addended reports were then manually assessed for any discrepancies in the reported spinal levels between the body and impression sections; the addenda corrected these errors (identified errors). In addition, all reports with the search term MR spine from January 2006 (n = 1,183) and January 2007 (n = 1,354) were assessed manually to recognize unidentified errors in spinal locations of reported pathology. Two neuroradiologists independently graded the clinical significance of errors on a 5-point scale (1 = definitely not significant, 5 = definitely significant).

Results

Of the 11,427 spinal MR reports analyzed in 2006, 7 had identified errors in the sites (levels of the spine) of the lesions. In 2007 (n = 11,785 spinal MR reports), 4 reports were detected with identified errors in spinal levels. In January 2006 and January 2007, 8 and 12 reports, respectively, had unidentified erroneous vertebral levels. Errors were related to discrepant vertebral regions (eg, cervical vs thoracic) in 16% of cases (5 of 31), the wrong number of vertebrae (eg, L2 instead of L3) in 68% of cases (21 of 31), and both in 16% of cases (5 of 31). The average time taken to issue an addendum was 5 ± 7 days in 2006 and 11 ± 13 days in 2007. Fifteen reports (48%) scored <3 on the scale of clinical significance, 1 report scored 3, and 15 scored >3.

Conclusions

Errors in lesion level 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 the vertebral levels of abnormalities.

Key Words: Radiology reporting, quality, errors, spinal MR