CT Dose Reporting Prone to Human Error

Institutions may have difficulty complying with the mandatory CT dose reporting law in California because reporting processes rely on manual data entry and are unreliable, according to a study published in the American Journal of Roentgenology.

Researchers from the Stanford School of Medicine in California undertook a retrospective review of reports to assess radiologist compliance with this legislation, which became effective on July 1, 2013.

The researchers assessed 664 chest CT examinations performed alone and combination CT examinations of the chest along with other contiguous regions, such as the abdomen, and noncontiguous regions, such as the head, performed at their institution from July 1, 2012, to June 30, 2013. Excluded were CT examinations that did not include scanning of the chest and CT angiography studies. They were looking for errors in documentation of volume CT dose index (CTDIvol), dose-length product (DLP), and phantom size.

Both CTDIvol and DLP had to be documented accurately to be considered legally compliant. Phantom size had to be accurately documented to be institutionally compliant. In addition, the researchers tracked reports that did not document dose in the standard format (phantom size, CTDIvol for each series, and total DLP).

The results showed several problems with the reporting:

Of 664 examinations, 599 (90.2%) met legal reporting requirements, and 583 (87.8%) met institutional requirements, the authors noted.

“Most reports were noncompliant owing to accuracy errors,” the authors wrote. “Even though reporting numerically accurate values would appear to be a simple task, it is ultimately prone to human error. 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.”

The researchers concluded that higher-reliability processes, including better-defined standards and automated dose-reporting systems, are necessary to improve compliance.