Lessons learned: audit of the record-keeping quality of a tertiary hospital’s mammography service

Abstract

Breast cancer is the most common cancer worldwide. In diagnostic centers offering mammography, periodic audit of medical archived procedures is an important component of a quality assurance program; this ensures optimal follow-up of positive cases and establishment of measures to combat any deficiencies. The study aimed to audit the record-keeping of the mammography service in a tertiary institution, with a view to improving its efficiency. A retrospective audit of request forms, questionnaires, mammograms, and reports of 1,098 women who had mammography at the radiology department of a public tertiary hospital between 2011 and 2018. An internal audit of records evaluated the completeness of clinical information on the request forms, questionnaires, accuracy of diagnosis, and state of stored mammographic films, years later. Microsoft Excel and SPSS version 23 were used for the analysis of descriptive and inferential statistics, respectively. Two hundred and thirty (21%) and 791 (72%) women had screening and diagnostic mammography, respectively; their ages ranged from 31 to 85 years. Indication of study was not stated on 73 (7%) request forms and 281 (26%) request forms were improperly filled. There were 52 (4.7%) women not clerked with the questionnaire, while 158 (14%) had no clinical breast examination prior to imaging. One hundred and thirty (12%) mammograms were damaged, while 2 were missing and not reviewed. Our study revealed a significant lapse in quality of our mammography record archival system. Evidence obtained helped institute necessary measures in place for digitization and quality control of mammography services.