Reporting Discrepancy Resolved by Findings and Time in 2947 Emergency Department Ankle X-rays

To identify common errors in ankle X-ray reporting between initial interpretation and final assessment at the virtual fracture clinic. Also, to assess time of initial reporting as a causative factor for discrepancy.

Two thousand nine hundred forty-seven final reports were reviewed by standard of agreement to the initial interpretation. Where discrepancy was found, it was classified and collated by specific finding. Comparison was made between reports with discrepancy and the complete dataset, allowing rates of error by finding to be established. The reports containing discrepancy were further classified by time period, this was compared against an expected value to establish if initial reporting outside of routine working hours was as accurate as that conducted within routine working hours.

94.4% of reports were in agreement with the initial interpretation, 2.9% contained minor discrepancy, and 2.7% major discrepancy. In 45.6% of reports there was no radiologically observable injury. 16.4% of reports contained a lateral malleolar fracture, most commonly Weber type B. 40.0% of all navicular fractures, and 33.3% of all cuboidal fractures were not commented upon in the initial reporting. Lower rates of more frequently observed findings were missed with 2.5% of Weber type B fractures not commented upon. An increased proportion of major discrepancy reports were generated from 00:00 to 07:59 (expected = 15.0%, observed = 22.2%; p = 0.07908). Similarly, a greater than expected number of minor discrepancy reports were found between 20:00 and 23:59 (expected = 18.0%, observed = 34.1%, p = 0.00025).

The initial reporting of ankle X-rays in the emergency department is performed to a high standard, however serious missed findings emphasise the need for timely senior review. Reporters should increase their awareness of navicular, cuboid, talar, and Weber A fractures which were missed at disproportionate rates. This study also finds evidence to support increased rates of error in initial reporting of ankle X-rays outside of normal working hours (17:00-07:59), particularly with a significantly increased rate of minor discrepancy seen from 20:00 to 23:59.