Human error a stumbling block in CT dose reporting requirements

A single-center study evaluating compliance with CT dose reporting legislation in California found that reliance upon correct human performance was inadequate to ensure accurate reporting and formatting of CT dosage information, according to study results published in the April issue of the American Journal of Roegentology.

In the wake of recent high-profile cases of overexposure to radiation in pediatric patients, researchers from the Lucile Packard Children’s Hospital at the Stanford University School of Medicine set out to evaluate their facility’s performance when it comes to CT dose reporting according to California Senate Bill 1237, which outlines new statewide dose-reporting requirements. “Specifically, both volume CT dose index (CTDIvol) and dose-length product (DLP) must be indicated in every radiology report when the information is available from the CT scanner,” wrote lead author Evan Zucker, MD, and colleagues. “We sought to evaluate compliance with both legal and institutional standards, with attention to the accuracy of dose information reported, and to evaluate areas for improvement.”

The researchers conducted a retrospective study of reports from all chest CT procedures performed at their medical facility from July 1, 2012, to June 30, 2013. They analyzed the reports for errors in documentation of CTDIvol, DLP and phantom size. They determined that if both CTDIvol and DLP were documented accurately, the reports were considered to be legally compliant. If those reports also accurately documented phantom size, they were considered to be institutionally compliant.

Their results revealed the institutional processes at the researchers’ facility were unreliable due to a reliance on error-free human performance, with approximately 10 percent of reports failing to meet legal compliance criteria while more than 12 percent failed to meet institutional compliance criteria. Dose report statements were also found to be prone to widespread variability in format.

“Even though reporting numerically accurate values would appear to be a simple task, it is ultimately prone to human error,” wrote Zucker et al. “Errors could have arisen from the radiologist’s dictating values incorrectly or the transcriptionist’s misunderstanding the values dictated, which were then not rechecked before report signature.”

Enhancements to the hospital’s dose reporting processes—and likely those of many other medical facilities around the country—are necessary to ensure the accuracy of CT dose information, according to Zucker and his team. “Higher-reliability processes, such as better-defined standards and implementation of automated dose reporting systems, may allow more consistent dose reporting,” the researchers wrote. “In view of this study, we are currently exploring such systems to improve compliance rates with dose reporting at our institution.”