Structured Reporting: An Intervention to Improve Procedure Documentation in Breast Imaging

Area of Science:

• Radiology
• Medical Informatics
• Patient Safety

Background:

• Wrong-site surgery can occur due to errors in localizing breast biopsy markers.
• Accurate documentation of biopsy markers is crucial for preventing surgical errors.
• Previous methods lacked consistent reporting of marker placement and characteristics.

Purpose of the Study:

• To evaluate the impact of structured reporting on the documentation of breast biopsy markers.
• To assess if structured reporting can reduce medical errors related to incorrect marker localization.
• To improve the quality of reporting for breast lesions requiring biopsy markers.

Main Methods:

• Retrospective review of breast core-needle biopsy reports from 2014 to 2020.
• Patients divided into three cohorts: pre-intervention (2014), pre-intervention/post-sentinel (2017), and post-intervention (2019).
• One hundred reports per cohort analyzed for documentation of marker presence and shape; statistical analysis using logistic regression and chi-squared tests.

Main Results:

• Documentation of both marker placement and shape significantly improved in the 2019 post-intervention cohort (94.6%) compared to 2014 (30.5%) and 2017 (69.2%).
• The proportion of biopsies with no marker placed or only marker reported decreased substantially after intervention.
• Statistical analysis confirmed a significant increase in complete marker and shape documentation in the structured reporting cohort (P < 0.05).

Conclusions:

• Structured reporting effectively enhances the documentation of breast biopsy markers and their characteristics.
• This improved documentation may lead to a reduction in medical errors, such as wrong-site surgery.
• The intervention demonstrates the value of structured reporting in improving procedural safety and diagnostic accuracy.