System approach to prevent lost studies and improve radiology report turn around time

From the 2021 HVPAA National Conference

Jacob Schick (Penn State College of Medicine), James Austin Baer (Penn State Hershey Medical Center), Jonelle Thomas


MR Pelvis examinations may represent studies of the prostate to be read by body imaging (BI) radiologists. They may alternatively represent examinations of the thigh musculature to be read by the musculoskeletal (MSK) radiologists. In our Picture Archiving and Communications System (PACS) and Radiology Information System (RIS), there was no way to differentiate these examinations as they are classified by the same CPT code. By default, the MR pelvis studies were listed on only the BI work list. Including them on the MSK work list would have clogged it up. This resulted in “lost” MSK MR Pelvis studies which did not receive timely reports. Some of these examinations had preliminary reports with substantiative changes made days later when found by the attending.


The goals of this project were to create a solution to prevent “lost” exams, improve report turn around time (RTAT), and improve patient care.


A pre-intervention list of 3 months of MR pelvis studies was obtained from the RIS. Audit logs were reviewed for each study to determine time to first view by BI and by MSK radiologists, time of report completion, time of preliminary report, and time of final signature. Mean times for time from completion to first MSK view and time to final report were calculated. Studies with delays in reporting resident misinterpretation were recorded.
An MSK reserve flag was placed in the PACS work list for the BI radiologists to use when they found an MSK study on their work list. The flag moved these studies onto the MSK reserve work list. After this intervention, another 3 months of data was analyzed. A second intervention was implemented where the technologists completing the studies and residents reading the studies were asked to also place the reserve flag. Additionally, if a BI radiologist placed a reserve flag on an ED or inpatient case, they were required to call or instant message an MSK attending to alert them of the study that needed urgent interpretation. After this, another 3 months of data was analyzed.


There was a significant improvement (p=0.0018) in time to view by MSK from pre-intervention mean of 1015 minutes (n=107) to post-intervention mean of 500 minutes (n=127). There was also a significant improvement (p=0.0033) in time to view inpatient and ED cases from 927 minutes to 357 minutes. Time from study completion to final signature also improved from a mean of 1764 minutes to 838 minutes, though not statistically significant (p=0.08). There were 5 cases of delay in reporting resident misinterpretation pre-intervention and none post intervention. Time to view overnight preliminary reports improved by 198 minutes after intervention.


Our intervention shows the importance of using different system tools and engaging different levels of patient care to solve a patient safety issue. Continuous monitoring is important to assess and adjust interventions. This reserve flag has been used in other divisions to solve similar problems and applied similarly to CT pelvis examinations.

Clinical Implications

Our project resulted in improved radiology report turn around times and earlier identification of resident discrepancies. This leads to improved patient care and prevention of morbidity from misdiagnosis.

What are academic medical centers across the country doing to improve healthcare value?

Value improvement guides: Published reviews in JAMA Internal Medicine coauthored by experienced faculty from multiple leading medical centers, with safety outcomes data and an implementation blue print.

Review article detailing 25 labs to refine for high value quality improvement | July 2020

MAVEN campaign: Free 4 year high value care curriculum online.

Join the Alliance! Membership is free with institutional approval and commitment to improving value in your medical center.

Learn more about HVPA on Health Affairs Blog