Audit Title:  Peer Review- Using Double Reporting as a Tool for Revalidation

Descriptor: An audit of double reporting by peer review for the purposes of appraisal and revalidation.


The process of Medical Recertification requires a doctor’s performance to be assessed in as objective a way as possible. Double reporting can be used as one of the tools to provide evidence to support an individual’s recertification portfolio, by providing evidence of reflective practice. This audit suggests a framework whereby the individual radiologist can use double reporting in a fair, and objective manner.


The cycle:


There is significant debate about how the accuracy of diagnostic tests should be calculated and reported in the literature.(1,2) There are no objective benchmarks for acceptable levels of observation or interpretation and ambiguity errors.(2,3) Therefore standards relating to the process are suggested.
1. An exercise in double reporting should be performed annually as part of Appraisal/Revalidation.
2. Appropriate cases should be referred to the local discrepancy meeting to facilitate learning. (4)
3. A summary detailing modality type, number of examinations and categorisation of feedback (7)should be produced. This report and supporting proformas should be then part of the individual’s consultant annual portfolio and should be presented for the purposes of appraisal/revalidation (5)



National                                             Local



100% for each of the above






































The Resources Used …

THE DATA was collected by ...

     ˙  Computer records                           ˙  Review of requests                        ˙  Other (specify)

     ˙  Review of images                           ˙  Ongoing data recording

     ˙  Review of reports                           ˙  Questionnaire



     ˙  None                                                 ˙  Data analysis                                  ˙  Other (specify)

      ˙  Secretarial                                        ˙  Software (off shelf)

     ˙  Audit office                                     ˙  Software (customised)

      ˙  Medical records                              ˙  Clinical professionals


TIME to help complete stages 1–3 of the first cycle


R A D I O L O G I S T                                                             R A D I O G R A P H E R                                             O T H E R ( s p e c i f y )

Approx _____ hrs per week                    Approx _____ hrs per week              Approx _____ hrs per week

for        _____ weeks                                 for        _____ weeks                          for        _____ weeks

= total   _____ hours                                = total  _____ hours                          = total  _____ hours


COSTS (stages 1–3 of the cycle) apart from radiologists’ / radiographers’ time

     ˙  None/minimal                                  ˙  Other (specify)                                Stages 1–3 of the first cycle


     ˙  Temporary staff

                ˙   Information technology


Results of the Completed Cycle…





















Comparison of findings …

(a) with the standard, shows that ...





(b) with the previous audit findings, shows that ...







(c) indicates that an improvement on the previous audit findings has occurred      ˙ Yes     ˙ No


A Further Audit will Occur

      in                                 months                                        to start (date) 


Useful References …

1.Peer review: Guidance on the use of double reporting RCR 2010
2. Standards for Reporting of Diagnostic Accuracy (STARD)
3. Soffa DJ, Lewis RS, Sunshine JH, Bhargavan M. Disagreement in interpretation: a method for the development of benchmarks for quality assurance in imaging. J Am Coll Radiol 2004; 1: 212–217.
4. Standards for the Reporting and Interpretation of Imaging Investigations. London: The Royal College of Radiologists, 2006.
5. Standards for Learning from Discrepancy Meetings. London: The Royal College of Radiologists, 2014
6. Standards for Self Assessment of Performance. London: The Royal College of Radiologists,2007
7. Quality assurance in radiology reporting: peer feedback. The Royal College of Radiologists, London. BFCR(14)10.

The Audit was carried out by …

Stages 1–4                                                               Stages 5–6




Address                                                                    Telephone No:





                                                                                Fax No:



A Copy of this form has been …


˙        placed in the Department’s Audit File


˙        sent to the Hospital’s Audit Office


˙        sent to the Clinical Audit Unit at the RCR



Appendix …

Further information (audit design / questionnaire / analysis of results / introduction of change)

is included as follows ...










© The Royal College of Radiologists 2015