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Objective comparison of errors and report length between structured and freeform abdominopelvic computed tomography reports

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Abstract

Purpose

To objectively compare structured and freeform abdominopelvic CT reports based on the number and types of errors as well as report length.

Methods

90 structured and 89 freeform reports from abdominopelvic CT scans with IV contrast obtained for the indication of abdominal pain were randomly selected for review. Each report was reviewed for errors, which were counted and categorized based on the type of error. The total number of words in each report was tallied.

Results

105 total errors were found in the structured reports, compared to 157 total errors in freeform reports. There were 1.16 errors per structured report and 1.76 errors per freeform report (p < 0.001). 48% of structured reports contained at least one error, while 71% of freeform reports contained at least one error (p = 0.002). When a difference existed between the styles with regard to error categories, more errors were observed in freeform reports, with the exception of the duplicated period error where structured reports had more errors. No difference on the basis of average words per report existed, with 219.2 words per report for each reporting style.

Conclusion

The use of structured reporting for abdominopelvic CT results in less errors in the report when compared to freeform reporting, potentially reducing clinically significant adverse outcomes in patient care. The report length on the basis of number of words per report is not different between the two reporting styles.

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Acknowledgements

Authors acknowledge Yufeng Li, PhD from the University of Alabama at Birmingham for her assistance with the statistical analysis

Funding

The authors have no sources of support in association with this manuscript.

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Authors and Affiliations

  1. Department of Radiology, University of Alabama at Birmingham, 619 19th St South, Birmingham, AL, 35249, USA

    J. Alex McFarland, Asser M. Abou Elkassem, Andrew D. Smith & Andrew J. Gunn

  2. University of Alabama at Birmingham School of Medicine, 1670 University Blvd, Birmingham, AL, 35233, USA

    Luke Casals & Grant D. Smith

Authors
  1. J. Alex McFarland
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  2. Asser M. Abou Elkassem
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  3. Luke Casals
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  4. Grant D. Smith
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  5. Andrew D. Smith
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  6. Andrew J. Gunn
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Contributions

JAM was responsible for project creation, project design, data collection, data analysis, and wrote the first draft of the manuscript; AMAE was responsible for data collection, data analysis, and manuscript editing; LC was responsible for data collection, data analysis, and manuscript editing; GDS was responsible for project design, data collection, data analysis, and manuscript editing; ADS was responsible for project design, data analysis, and manuscript editing; AJG was responsible for project creation, project design, data analysis, final draft of the manuscript, and supervision of team members.

Corresponding author

Correspondence to Andrew J. Gunn.

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Conflict of interest

The authors have no conflict of interest in association with this manuscript.

Ethical approval

The study was approved by our institutional review board (IRB) at the University of Alabama at Birmingham, which waived any requirement for patients to consent to participate or have the data published.

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McFarland, J.A., Elkassem, A.M.A., Casals, L. et al. Objective comparison of errors and report length between structured and freeform abdominopelvic computed tomography reports. Abdom Radiol 46, 387–393 (2021). https://doi.org/10.1007/s00261-020-02646-9

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  • DOI: https://doi.org/10.1007/s00261-020-02646-9

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