Objectives: To compare the accuracy of diagnostic interpretation of radiographs by pediatric emergency physicians (EPs) before and after the introduction of a Picture Archiving and Communications System (PACS). Methods: The pre‐PACS study period included results from September 2001, when patients were evaluated by using only conventional radiographs. The post‐PACS study period consisted of results from September 2002, when patients were evaluated by using only digital radiographic studies. During these periods, consecutive medical records of all patients who underwent radiological studies when attending the pediatric emergency department (ED) were reviewed. The radiographic interpretation by the pediatric EP, documented at the time of the ED visit, was compared with that made by the pediatric radiologist. Results: Data were available from 1,644/1,651 sets of conventional radiographs ordered for the pre‐PACS study period and from 1,430/1,431 sets of digital radiographic studies for the post‐PACS study period. The prevalence of positive radiological studies as per the radiologists was 32.2% (pre‐PACS study period) vs. 28.7% (post‐PACS study period). Diagnostic performance of the pediatric EPs for the two time periods was as follows: overall accuracy, 98.1% (95% confidence interval [CI] = 94.5% to 100%) vs. 98.5% (95% CI = 87.5% to 100%); sensitivity, 96.4% (95% CI = 94.5% to 97.8%) vs. 98.1% (95% CI = 96.2% to 99.2%); specificity, 98.9% (95% CI = 98.1% to 99.4%) vs. 98.6% (95% CI = 97.7% to 99.3%); negative predictive value, 98.3% (95% CI = 97.4% to 99.0%) vs. 99.2% (95% CI = 98.5% to 99.7%); and positive predictive value, 97.7% (95% CI = 96.0% to 98.8%) vs. 96.6% (95% CI = 94.4% to 98.2%). The proportion of false negatives (FN) was 1.2% (19/1,644) vs. 0.6% (8/1,430). Only one FN patient for each time period required immediate follow‐up for a missed diagnosis. Conclusions: Radiograph interpretations by pediatric EPs with digital studies remain as accurate in comparison with assessments performed by using conventional radiographs.