Decision-making in the referral process of sonographers in primary care screening centers†

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To explore the decision-making process (whether or not to refer) of sonographers performing the 20 weeks standard anomaly scan (SAS) in the screening setting.


A survey was sent to SAS-sonographers; it assessed experience, training, volume, type of practice, perceived difficulty per organ system, feelings after missing anomalies and reasons for uncertainty and doubt concerning referral.


The response rate was 50%. Sonographers tend to seek reasons for uncertainty in patient factors and not in their skills or difficulty of the scan. Most mentioned reasons to refer in case of doubt were repeated visualization of a possible abnormality (98%). We hypothesize that the need of repeated imaging of an abnormality might partly explain why some fetal anomalies are still being missed. Sonographers with limited experience and low volume SAS more often revised, referred and asked colleagues for help than experienced sonographers with high volume SAS. In cases of a missed diagnosis, sonographers frequently blamed internal factors (personal failure 71%).


Level of experience and volume of SAS influence revision and referral rates. Personal factors seem to play a role in the decision-making process of screening sonographers. Future research should focus on these personal factors, to optimize screening ultrasound programs. © 2016 John Wiley & Sons, Ltd.

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