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预填充放射科报告模板:错误率和周转时间的前瞻性分析。

Prepopulated radiology report templates: a prospective analysis of error rate and turnaround time.

机构信息

Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, ML 5031, Cincinnati, OH 45229, USA.

出版信息

J Digit Imaging. 2012 Aug;25(4):504-11. doi: 10.1007/s10278-012-9455-9.

Abstract

Current speech recognition software allows exam-specific standard reports to be prepopulated into the dictation field based on the radiology information system procedure code. While it is thought that prepopulating reports can decrease the time required to dictate a study and the overall number of errors in the final report, this hypothesis has not been studied in a clinical setting. A prospective study was performed. During the first week, radiologists dictated all studies using prepopulated standard reports. During the second week, all studies were dictated after prepopulated reports had been disabled. Final radiology reports were evaluated for 11 different types of errors. Each error within a report was classified individually. The median time required to dictate an exam was compared between the 2 weeks. There were 12,387 reports dictated during the study, of which, 1,173 randomly distributed reports were analyzed for errors. There was no difference in the number of errors per report between the 2 weeks; however, radiologists overwhelmingly preferred using a standard report both weeks. Grammatical errors were by far the most common error type, followed by missense errors and errors of omission. There was no significant difference in the median dictation time when comparing studies performed each week. The use of prepopulated reports does not alone affect the error rate or dictation time of radiology reports. While it is a useful feature for radiologists, it must be coupled with other strategies in order to decrease errors.

摘要

目前的语音识别软件允许根据放射信息系统的程序代码,将特定于检查的标准报告预填充到听写字段中。虽然人们认为预填充报告可以减少口述研究所需的时间,并减少最终报告中的错误总数,但这一假设尚未在临床环境中进行研究。进行了一项前瞻性研究。在第一周,放射科医生使用预填充的标准报告口述所有研究。在第二周,在禁用预填充报告后,所有研究都进行了口述。最后对放射学报告进行了 11 种不同类型的错误评估。报告中的每个错误都单独分类。比较了两周之间口述检查所需的中位数时间。在研究期间,共口述了 12387 份报告,其中随机分析了 1173 份报告的错误。两周内每份报告的错误数量没有差异;然而,放射科医生在两周内都非常喜欢使用标准报告。语法错误是最常见的错误类型,其次是误义错误和遗漏错误。比较每周进行的研究时,中位数口述时间没有显著差异。预填充报告的使用本身并不会影响放射学报告的错误率或口述时间。虽然它对放射科医生来说是一个有用的功能,但必须与其他策略结合使用,才能减少错误。

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