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Acad Emerg Med. 2019 Nov 8. doi: 10.1111/acem.13884. [Epub ahead of print]

Adverse Events from Emergency Physician Pediatric Extremity Radiograph Interpretations: A Prospective Cohort Study.

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Division of Pediatric Emergency Medicine, Department of Pediatrics, Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
Division of Pediatric Emergency Medicine, Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada.
Department of Radiology, Christian Medical College and Hospital, Vellore, Tamil Nadu, India.
Department of Diagnostic Imaging, Hospital for Sick Children, University of Toronto, Toronto, Canada.
Division of Orthopedic Surgery, Department of Surgery, Hospital for Sick Children, University of Toronto.
Faculty of Medicine, University of British Columbia, Vancouver, British Columbia.
Division of Pediatric Emergency Medicine, Department of Pediatrics, Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.



We determined how often emergency physician pediatric musculoskeletal (MSK) radiograph interpretations were discordant to that of a radiologist and led to an adverse event (AE). We also established the variables independently associated with this outcome.


This prospective cohort study was conducted in an urban, tertiary care children's emergency department (ED). We enrolled children who presented to an ED with an extremity injury and received radiographs. ED physicians documented their radiograph interpretation which was compared to a radiology reference standard. Patients received telephone follow up and had institutional medical records reviewed at three weeks. An AE occurred if there were clinical sequelae and/or repeat health care visits due to a delay in correct radiograph interpretation.


We enrolled 2,302 children [mean (SD) age 9.0 (4.4) years; 1,288 (56.0 %) male]. Of these, 180 (7.8%; 95% CI 6.8, 9.0) ED physician discordant interpretations resulted in an AE. Specifically, there were no negative clinical outcomes; however, relative to cases diagnosed correctly at the index ED, patients whose fracture was not initially identified encountered 77.2% more subsequent ED visits, while those falsely diagnosed with a fracture experienced 41.5% additional orthopedic clinic visits. Odds of an ED discrepant interpretation were significantly higher if a physician's pre-test probability of a fracture was ≤20% vs. >20% (adjusted Odds Ratio, aOR 1.6), patient's pain score ≤ 2 vs. >2 (aOR 1.6), and injury was located in a joint versus other location (aOR 1.7).


Emergency physician discordant pediatric MSK radiograph interpretations that resulted in an AE occurred with regular frequency in a pediatric ED setting. AE's were primarily an increase in subsequent health care visits. Importantly, a low clinical suspicion for a fracture or injury located in the joint were risk factors for ED physician discordant interpretations.


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