BACKGROUND: Pediatric emergency department chest radiographs are frequently interpreted by the pediatrician, and patient management is based on this interpretation. OBJECTIVE: The purpose of this study was to assess the chest radiograph interpretation discordance rate between pediatricians and pediatric radiologists and determine its clinical significance. METHODS: This study included 1196 patients admitted off-hours to the pediatric emergency department who had chest radiographs as part of the clinical evaluation. The pediatricians' interpretations of the chest radiographs as appeared in the discharge reports were reviewed and compared with the specialist radiologist's ultimate report. RESULTS: Discordant chest radiograph interpretations were found in 332 (28%) of 1196 patients. Of these, 76 (6.3%) were clinically significant. These included 59 initial diagnoses of normal or viral patterns subsequently interpreted as bacterial pattern by the radiologist and 17 radiographs with findings such as chronic lung disease or abnormal heart shadow overlooked or misinterpreted by the pediatrician. CONCLUSIONS: Although the clinically significant discordant rate was relatively low, daily chest radiograph reassessment by pediatric radiologists in a joint meeting with pediatricians has an added value for patient safety, quality assurance, and mutual training.