Impact of Patient Photographs on Radiologists' Visual Search of Chest Radiographs

Rationale and Objectives

To increase detection of mislabeled medical imaging studies, evidence shows it may be useful to include patient photographs during interpretation. This study examined how inclusion of photographs impacts visual search.

Materials and Methods

Ten radiologists participated. Average age was 43.00 years and average years Board-certified was 9.70, with 2 residents, 1 general, 2 abdominal, 4 cardiothoracic, and 1 pediatric radiologist. They viewed 21 portable chest radiographs with and without a simultaneously acquired photograph of the patient while visual search was recorded. Their task was to note placement of lines and tubes.

Results

Presence of the photograph reduced the number of fixations (chest radiograph only mean 98.68; chest with photograph present 80.81; photograph 10.59; p < 0.0001) and total dwell (chest radiograph only mean 30.84 seconds; chest radiograph with photograph present 25.68; photograph 3.93; p < 0.0001) on the chest radiograph as a result of periodically looking at the photograph. Overall viewing time did not increase with addition of the photograph because time not spent on the radiograph was spent on the photograph. On average, readers scanned from the radiograph to the photographs about four times during search. Men and non-cardiothoracic radiologists spent significantly more time scanning all the images, including the photographs. Average preference for having photographs was 6.10 on a 0–10 scale, and neck and chest were preferred as areas to include in the photograph.

Conclusion

Photographs may help with certain image interpretation tasks and may help personalize the reading experience for radiologists without increasing interpretation time.

Introduction

The Institute of Medicine’s Committee on Quality of Health Care in America estimated that as many as 98,000 people die each year from medical errors . In radiology, a potential source of error is the wrong-patient error , which happens when a patient’s radiograph is incorrectly filed under a different patient’s folder in the Picture Archiving and Communication System (PACS). For example, one Pennsylvania study demonstrated that 196 of 652 (30.1%) error events in radiology in 1 year that resulted in serious patient harm were wrong-patient errors .

To minimize such identification errors, The Joint Commission in its National Patient Safety Goals outlines the requirement of including at least two patient identifiers when providing care, treatment, and services. These identifiers may include the individual’s name, an assigned medical record number, telephone number, or other person-specific identifier, such as date of birth or social security number . However, when mobile or portable radiographs are obtained in high-stress environments outside of the radiology department, such as in the emergency department or in the intensive care unit (ICU), where patients often cannot accurately provide identification information due to sedation, intoxication, alteration in consciousness, or inability to communicate for other reasons, the setting is ripe for wrong-patient errors to occur .

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Material and Methods

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Radiologists

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Radiograph Review Task Design

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Eye-Tracking Analysis

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Survey and Data Analysis

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Results

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Table 1

Radiologists’ Frequency of Responses in Each Category for the Pre- and Post-Study Surveys with Test Value and P -Value in the Right Columns

Question Significantly Less Slightly Less No Difference Slightly More Significantly More χ 2 P -Value Pre-study (without photos) Call referring critical result 0 0 0 0 10 40.00 <.0001 Call referring important finding 0 0 1 2 7 17.00 <.001 Look up patient info 0 0 1 0 9 31.00 <.0001 Post-study (with photos) Accurate interpretation images 0 1 2 5 2 7.00 NS Accurate interpretation lines and tubes 0 1 0 4 5 11.00 <.05 Accurate ID mislabeled patients 0 0 1 7 2 17.00 <.001 Accurate evaluation health status 0 0 3 5 2 9.00 NS Spend time interpretation 0 1 2 5 2 7.00 NS Comfortable photo present 0 3 4 2 1 5.00 NS Distracted photo present 1 0 6 2 1 11.00 <.05 Call referring critical with photo 0 0 7 2 1 17.00 <.001 Call referring important with photo 0 0 6 3 1 13.00 <.02 Look up patient info with photo 0 2 6 1 1 11.00 <.05

NS, not significant.

Table 2

Radiologists’ Frequency of Yes Versus No Responses for Which Body Areas Should Be Included in the Photographs with Test Value and P -Value in the Right Columns

Areas to Include Yes No χ 2 P -Value Face 5 5 0.00 NS Neck 9 1 6.40 .02 Chest 8 2 3.60 NS Abdomen 3 7 1.60 NS

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Table 3

Results of the Eye-Tracking Study Using ANOVA with the Means and Standard Deviations for Each of the Three Images

Eye-Tracking Parameter Radiograph Alone (1)

(SD) Radiograph with Photograph (2) Photograph (3) F-Value_P_ -Value PLSD No. of fixations 98.68(68.43) 80.81(53.99) 10.59(9.59) 198.93 <.0001 1 vs 3 1 vs 3 2 vs 3 Mean fixation duration (s) 0.31(0.04) 0.30(0.04) 0.37(0.14) 40.19 <.0001 1 vs 3 2 vs 3 Total dwell (s) 30.84(21.07) 25.68(28.24) 3.93(3.81) 90.82 <.0001 1 vs 2 1 vs 3 2 vs 3 Dwell first fixation (s) 0.23(0.13) 0.22(0.13) 0.30(0.19) 11.69 <.0001 1 vs 3 2 vs 3 No. of visits to image 1.77(2.16) 4.70(3.31) 3.15(2.85) 104.70 <.0001 1 vs 2 1 vs 3 2 vs 3

ANOVA, analysis of variance; PLSD, protected least squares difference; SD, standard deviation.

Note: The last column on the right shows which conditions differed significantly when tested with the PLSD test (1 = radiograph alone, 2 = radiograph with photograph, 3 = photograph).

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Discussion

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Prior Work

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Limitations

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Conclusions

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Acknowledgements

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Appendix

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Please mark the best option: Significantly less Slightly less No difference Slightly more Significantly more I am______ likely to call the referring provider if I detect a critical result. I am______ likely to call the referring provider if I detect an important finding. I am______ likely to look up patient information in the electronic medical record to clarify my report if I am unsure of the radiographic findings. Your age: Your gender (circle one):

Male/Female Subspecialty area of practice:

(a) In training

(b) General Radiologist

(d ) Breast

(e) Cardiothoracic

(f) Interventional

(g) Musculoskeletal

(h) Neuroradiology

(i) Pediatric Years in practice as a Board-certified radiologist: ___years

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Please mark the best option: Significantly less Slightly less No difference Slightly more Significantly more Having patients’ photographs available: could result in ______accurate interpretation of images. could result in ______accurate interpretation of lines and tubes. could result in ______accurate identification of mislabeled patients. could result in ______accurate evaluation of patient health status. could result in spending ______ time for interpretation of imaging test. I felt ______ comfortable interpreting imaging tests with the photographs present. I felt ______ distracted from concentrating on accurate imaging interpretation with the photographs present. I would be______ likely to call a report to the referring provider if I detect a critical result with the photographs present than without. I would be______ likely to call the referring provider if I detect an important finding with the photographs present than without. I would be______ likely to look up patient information in the electronic medical record to clarify my report if I am unsure of the radiographic findings with the photographs present than without.

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Open full size image

Your age: Your gender (circle one):

Male/Female In your opinion, which body parts should be included in the patient’s photograph for a chest radiograph? (Check all that apply.)

(a) Face

(b) Neck

(d) Abdomen

(e) Other (please specify ) _____________ Subspecialty area of practice:

(j) In training

(k) General Radiologist

(l) Body

(m) Breast

(n) Cardiothoracic

(o) Interventional

(p) Musculoskeletal

(q) Neuroradiology

(r) Pediatric Years in practice as a Board-certified radiologist: ___years

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References

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Impact of Patient Photographs on Radiologists' Visual Search of Chest Radiographs

Rationale and Objectives

Materials and Methods

Results

Conclusion

Introduction

Material and Methods

Radiologists

Radiograph Review Task Design

Eye-Tracking Analysis

Survey and Data Analysis

Results

Discussion

Prior Work

Limitations

Conclusions

Acknowledgements

Appendix

References

Further Reading

Algorithm Variability in the Estimation of Lung Nodule Volume From Phantom CT Scans Results of the QIBA 3A Public Challenge

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Association between Breast Parenchymal Complexity and False-Positive Recall From Digital Mammography Versus Breast Tomosynthesis