radiology errors and negligence
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RADIOLOGY ERRORS AND NEGLIGENCEVenue: British Dental Association, London
CPD: 5 CREDITS
6FEBRUARY
2015
More information available soon at www.bir.org.uk
• Room1Primers for the non-specialistsSessionorganisedbyDrDavid
Wilson,ConsultantInterventional
MSKradiologist,OxfordUniversity
HospitalsNHSTrust
• Room2Radiation protectionSessionorganisedbyMrAndy
Rogers,HeadofRadiationPhysics,
NottinghamUniversityHospitals
NHSTrust
Save the date
• Room1Clinical hybrid imaging inoncologySessionorganisedbyDrGopinath
Gnanasegaran,Consultant
PhysicianinNuclearMedicine,St
Thomas’Hospital
• Room2Emergency radiologySessionorganisedbyDrHardi
Madani,RadiologyRegistrar,Royal
freeLondonHospital
Essentials for the radiology traineeSessionorganisedbyDrHardi
Madani,RadiologyRegistrar,
RoyalFreeLondonHospital,and
DrAusamiAbbas,Cardiothoracic
RadiologyPostCCTFellow,
UniversityHospitalAlberta
Day 2Day 1
BIR ANNUAL CONGRESS 20154–5 NOVEMBER
LONDON
We are most grateful to
1
Save the date
Day 2
Welcomeandthankyouforcomingto‘Radiologyerrorsandnegligence’organisedbyTheBritishInstituteofRadiology.
Wewishyouaveryenjoyableandeducationalexperience.
Certificateofattendance
Thismeetinghasbeenawarded5RCRcategoryICPDcredits.
Yourcertificateofattendancewillbeemailedtoyouwithinthenexttwoweeksonceyouhavecompletedtheonlineeventsurveyat:
https://www.surveymonkey.com/s/radiologyerrorsandnegligence
BIR Annual Congress 2015: 4–5 November, London
We are most grateful to
for supporting this conference.
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Programme
09:00 Registration and refreshments
09:25 Welcome and introduction DrTeikChoonSee,ConsultantRadiologist,Addenbrooke’sHospital
09:35 Errors in radiology DrTeikChoonSee,ConsultantRadiologist,Addenbrooke’sHospital
10:05 Discrepancy meetings: moving forwards DrMaryRoddie,ConsultantRadiologist, ImperialCollegeHealthcareNHSTrust
10:35 Maintaining high professional standards framework MrStuartCraig,PartnerforMills&ReeveLLP
11:05 Refreshments
11:30 Integrating human factor in radiology ProfessorBrynBaxendale,ConsultantAnaesthetist,UniversityofNottingham
12:00 Thoracic imaging DrNickScreaton,ConsultantCardiothoracicRadiologist,PapworthHospital
12:30 Lunch
13:30 Abdominal trauma imaging DrSaraUpponi,ConsultantRadiologist,Addenbrooke’sHospital
14:00 MSK imaging DrAndoniToms,ConsultantRadiologist, NorfolkandNorwichUniversityHospitals
14:30 Breast imaging DrMatthewWallis,ConsultantRadiologist,Addenbrooke’sHospital
15:00 Refreshments
15:30 Paediatric imaging DrCarenLandes,ConsultantPaediatricRadiologistand RadiologyClinicalLead,AlderHeyChildren’sNHSFoundationTrust
16:00 Head and neck imaging DrElizabethLoney,ConsultantRadiologist,BradfordTeachingHospitals
16:30 Quality assurance in radiology reporting: peer feedback DrRichardFitzGerald,Vice-President,FacultyofClinicalRadiology, TheRoyalCollegeofRadiologists
17:00 Close of event
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Certificate of attendance
Thismeetinghasbeenawarded5RCRcategoryICPDcredits.
Yourcertificateofattendancewillbeemailedtoyouwithinthenexttwoweeksonceyouhavecompletedtheonlineeventsurveyat:
https://www.surveymonkey.com/s/radiologyerrorsandnegligence
BIR Annual Congress 2015: 4–5 November, London
Join the BIR today and receive 20% off your membership fee
Asathankyouforattendingtoday’seventwewouldliketoofferyouthisgreatdeal
Be part of the only multi-disciplinary membership organisation for everyone interested in medical imaging
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Speaker profiles
Professor Bryn BaxendaleConsultant Anaesthetist, University of Nottingham
BrynwasappointedasaConsultantAnaesthetistatNottinghamUniversityHospitalsin1998andcurrentlyhasclinicalresponsibilitiesrelatedprimarilytovascularandemergencysurgicalservicesatQMCcampus.In2009hewasappointedasanHonoraryProfessorbytheSchoolofPsychologyattheUniversityofNottingham.
HehasbeenPresidentoftheAssociationofSimulatedPracticeinHealthcare(2009–2014),whichisthenationallearnedbodyinrelationtotheuseofsimulationandrelatedinnovativelearningtechnologiesforprofessionaleducationandtraining,workforcedevelopment,andqualityandpatientsafetyimprovement.In2012BrynjoinedtheHealthEducationEngland(HEE)StrategyBoardforTechnologyEnhancedLearning,andisalsoamemberoftheHEEHumanFactorsExpertWorkingGroup.
Hisinterestsrelatetoleadingthewidespreadadoptionofsimulation-basedmethodologiesacrossthehealthcaresysteminordertoenhancepatientsafetyandqualityofcare.Specificallythisinvolvesexplorationofhowbesttoenhancethedevelopmentofexpertiseinindividualprofessionalsandmultiprofessionalteams,andhowtosupportorganisationallearningandattainmentofhighreliabilityamidstcomplexityandconstrainedresources.
Mr Stuart CraigPartner for Mills & Reeve LLP
StuartisaPartnerwithnationallawfirmMills&ReeveLLPspecialisinginemploymentlaw.HefrequentlyadvisesonmatterswherespecialistknowledgeoftheNHSisrequired,inparticularinrelationtodisciplinaryandperformanceissuesinvolvingmedicalpractitioners.Stuart’sexpertisehasbeenacknowledgedbytheleadingindependentlegaldirectories,inwhichheisdescribedas“highlyrecommendedinthehealthcaresector”andasan“outstandinglawyerappreciatedforhiswisesolutions.”
Dr Richard FitzGeraldVice-President, Faculty of Clinical Radiology, The Royal College of Radiologists
• ConsultantRadiologist,RoyalWolverhamptonHospitalsNHSTrust1986-March2014,part-timeMay2014onwards
• Chairman,WestMidlandsAssociationofRadiologists1997-1999• ElectedMemberofRoyalCollegeofRadiologists(RCR)RadiologyFacultyBoard
1999-2002• MemberoftheRCRStandardsSubcommittee2003-2009andRCREuropean
Subcommittee2001-2009• ElectedMemberofRCRCouncil2010-2013
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• ElectedMemberofRadiologyProfessionalSupportandStandardsBoard2011-2014
• GeneralMedicalCouncilRadiologistAssessor2002-2013• MemberofvariouslocalandnationalBMACommittees1994-2010• PublicationsandlecturesonImprovingRadiologistWorkingLives,FairMedical
Regulation,RadiologicalErrorandTeleradiology
Dr Caren LandesConsultant Paediatric Radiologist and Radiology Clinical Lead, Alder Hey Children’s NHS Foundation Trust
CarenisaConsultantPaediatricRadiologistandServiceGroupLeadatAlderHeyChildren’sNHSFoundationTrust.
HerexpertisewithinpaediatricradiologycoversthefullrangeofpaediatricimagingincludingplainX-ray,ultrasound,fluoroscopy,crosssectionalimaging(CTandMRI)andnuclearmedicine,butshehasaspecialinterestinmusculoskeletalradiologyandimaginginsuspectednon-accidentalinjury.
DrLandeshasleadtheDepartmentalDiscrepancyMeetingfor3yearsuntil2012andasaresultofherexpertiseshereceivesregionalandnationalreferralsforreviewofmusculoskeletalimagingfromradiologicalandclinicalcolleagueswithanemphasisonimagingincasesofsuspectednon-accidentalinjury.Asaresultofthisshehasexperienceofdiscrepanciesseeninpaediatricimaginginboththetertiarysettingandinthereferringhospitals.
Dr Elizabeth LoneyConsultant Radiologist, Bradford Teaching Hospitals
ElizabethisaConsultantHeadandNeckRadiologistatBradfordTeachingHospitalsNHSFoundationTrustwhereshehasworkedforthelast8years.PriortothisshewasaConsultantRadiologistatQueensHospital,BurtononTrent,for3yearsanddidherRadiologyTrainingatTheRoyalFreeandStMarys’Hospitals,London.
Sheoriginallystudiedtobeanear,noseandthroat(ENT)Surgeonbutafter‘seeingthelight-box’decidedtocombineherinterestinHeadandNeckwithAnatomyinaRadiologicalcareer.SheiscurrentlytheVice-ChairandChairmanElectoftheBritishSocietyofHeadandNeckImagingandobtainedtheEuropeanDiplomaofHeadandNeckRadiologyin2013,becomingaFellowofESHNR.
Elizabethlecturesnationallyandinternationallyonallthings‘HeadandNeck’.Herpracticecoversallmodalitiesexceptnuclearmedicine,andallareasfromtheclavicleupwardsincludingimagingforcochlear,middleearandTMJimplantation.AstheonlyUKmemberoftheScientificSubcommitteeforTheEuropeanCongressofRadiology(ECR)2015and2016shehasbeeninvolvedinvettingandscoringover150abstractsandisalsolecturingatECRinMarch2015.SheisapastPart1FRCRAnatomyExaminer,beingoneofthefoundingmembersoftheAnatomyWorking
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Group.ShealsoexaminesAnatomyfortheRoyalCollegeofSurgeonsofEnglandbothintheUKandabroad.
Elizabethreviewsfor8JournalsincludingClinicalRadiology,EuropeanRadiologyandtheBritish Journal of Oral and Maxillofacial Surgery.SheconvenesanannualcourseinAnatomyforFRCRpart1inLeedsandisSpecialInterestLeadfortheLeeds–BradfordRadiologyAcademyinHeadandNeck.SheisanextremelyenthusiasticteacherandkeentodisseminateherknowledgeofHeadandNeckImagingtoallwhoareinterested.
Dr Mary Roddie,Consultant Radiologist, Imperial College Healthcare NHS Trust
MaryisaThoracicRadiologistatImperialCollegeHealthcareNHSTrustandHonorarysecretaryoftheBritishSocietyofThoracicRadiology.HerinterestsincludethoracicultrasoundandthedevelopmentofdigitalteachingcollectionsofimagesandsherunscoursesonbothofthesesubjectsaswellasbeingafoundermemberoftheUKOsiriXusergroup.ShehasbeeninvolvedinthediscrepancymeetingprogrammeatImperialCollegeHealthcareNHSTrustsinceitsinceptionandhasmorerecentlydevelopedaninnovativevirtualdiscrepancymeetingformatthathasdemonstratedincreasedradiologistinvolvementinandengagementwiththeprocess.
Dr Nick ScreatonConsultant Cardiothoracic Radiologist, Papworth Hospital
NickisaConsultantCardiothoracicRadiologistatPapworthHospital,Cambridge.Hisspecialinterestsincludepulmonaryhypertension,interstitialandairwaysdiseases,andlungcancerscreening.HewasRadiologyClinicalDirectorinPapworthHospital2004–12andPresidentoftheBritishSocietyofThoracicImaging2009–13.HesitsontheBritishThoracicSocietyBronchiectasisGuidelinesdevelopmentgroup,NationalInstituteofClinicalExcellenceIdiopathicPulmonaryFibrosisQualityStandardsCommittee,NationalInstituteofClinicalExcellenceGuidelinesUpdatesStandingCommittee,andNationalClinicalCommissioninggroupforSpecialisedimaging(stakeholderrepresentative).
Dr Teik Choon SeeConsultant Radiologist, Addenbrooke’s Hospital
TeikChoonisaConsultantInterventionalRadiologistatAddenbrooke’sHospital,Cambridge.Hisspecialinterestsincludehepato-biliaryinterventionsandinterventionaloncology.Heisactivelyinvolvedinclinicalgovernance,managementofradiologyerrorsandqualityimprovementlocallyandnationally.HechairedtheBIREastofEnglandbranchsinceitsinceptionin2010to2013.Heinitiatedanumberoflocal,regionalandnationaleducationaleventsrelatedtointerventionalradiology,patientsafety,radiologyerrorsandtheCambridgeFRCRcourse.
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Dr Andoni TomsConsultant Radiologist, Norfolk and Norwich University Hospitals
AndoniisaMusculoskeletalRadiologistattheNorfolkandNorwichUniversityHospitalandanHonoraryProfessorattheUniversityofEastAnglia.HegraduatedfromMedicalSchoolinLondonin1991,completedhisRadiologytraininginCambridgein2001andaMusculoskeletalRadiologyFellowshipattheUniversityofTorontoin2002.HewasappointedaConsultantRadiologistatNorfolkandNorwichUniversityHospitalsNHSFoundationTrustin2002.Hisparticularareasofimagingresearchinterestincludetheimagingoforthopaedicprostheses—thebasisforhisPhDawardedin2011—andosteoarthritis.Hehaspublishedover90peerreviewedpapersandgivenover40invitedlecturesatnationalandinternationalscientificconferences.
Dr Sara UpponiConsultant Radiologist, Addenbrooke’s Hospital
SaraisaConsultantRadiologistatAddenbrookesHospitalCambridgewithinterestsinabdominalandtraumaimaging.Sheisclinicalleadfortraumaimagingandhasbeenco-leadforthelocaldiscrepancymeetingforthelast6years.
Dr Matthew WallisConsultant Radiologist, Addenbrooke’s Hospital
• ConsultantRadiologist,CambridgeBreastUnitsinceNovember2007• AssociateLecturer,UniversityofCambridge• DirectorofScreeningsinceJuly2010–September2014• BeforethatDirector,Warwickshire,SolihullandCoventryBreastScreening
Programmefor19years• PastPresident,EuropeanSocietyofBreastImaging2010–2013• Clinicalimaginglead(Breast)attheCambridgeBiomedicalResearchCentreand
theExperimentalCancerMedicineUnit: -Monitoringandpredictingbreasttumourresponseinphase1and2trials -Optimisingexistingandevaluatingnewimagingtechniquesforthebreast andaxilla• Hisotherresearchinterestisanythingandeverythingaffectingradiologicaland
surgicalperformanceinbreastscreeningandusingdatatoimproveperformance.Inparticularrelatedtononoperativediagnosis,stagingofthebreastandthediagnosisandmanagementofductalcarcinomainsitu
• 86peerreviewpapers
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Abstracts
Errors in radiologyDr T C See
Learningobjectives:• Radiologyerrorsaremultifactorial.Asystematicapproachisrequiredto
minimiseerrors• Themostcommoncauseofmedicalmalpracticesuitsagainstradiologists
iserrorindiagnosis,followedbyproceduralcomplicationsandinadequatecommunication
• Thelargestnumberofclaimsconcernedmissedordelayeddiagnosesofcancer
• Adheretostandardofcareandminimiserisks:PracticeandQualityImprovementGuidelines,PatientSafetyChecklist,TrainingandUpdates,ImproveCommunicationSkills,LiabilityInsurance
Discrepancy meetings: moving forwardsDr Mary Roddie
Departmentaldiscrepancymeetingsfacilitatecollectivelearningfromradiologydiscrepanciesanderrorsandthusimprovepatientsafety.RoyalCollegeofRadiologistsstandardsstatethatallradiologistsshouldparticipateregularlyinradiologydiscrepancymeetingswithaminimumattendanceofatleast50%ofmeetings.Withincreasingpressureonradiologists’stimeandinlargeTrustsspreadacrossdifferenthospitalsitmaybedifficultforradiologiststoattendandparticipateindiscrepancymeetings.Thispresentationwilldescribeaninnovativevirtualdiscrepancymeetingformatthathasmadeasignificantimprovementinradiologistattendanceandengagementwiththesharedlearningprocessofdiscrepancyanalysis.Ithasalsogreatlyincreasedthenumberofcasesbeingsubmittedforinclusionandanalysis.
Maintaining high professional standards frameworkMr Stuart Craig
“MaintainingHighProfessionalStandardsInTheModernNHS”(“MHPS”)istheframeworksettingouthowconcernsthatariseinrespectofmedicalpractitionersemployedintheNHSshouldbehandled.Inthedecadesinceitwasintroducedithasgivenrisetomanyissuesandlegaldisputes.Inthissession,StuartCraig,aPartnerwithnationallawfirmMills&ReeveLLP,willsummarisetheissuesthathavearisenandexaminethelessonstobelearntfromarecentleadingHighCourtdecisioninwhichStuartwasinvolved.
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Integrating human factor in radiologyProfessor Bryn Baxendale
ThispresentationwilldescribetherelevanceofHumanFactor(HF)sciencetoprofessionalpracticeinhealthcare,withemphasisonhowhumanfallibilityandlimitationsinperformanceareeverpresentinourdailylivesatworkandathome.StrategiestoimproveawarenessamongststaffandbuildHFcapabilityandorganisationalresiliencewithinlocalteamsandserviceswillbeoutlined.
Thoracic imagingDr Nick Screaton
Aswithotherorgansystems,errorinchestimagingmayrangefromperceptualerror(overorundercalling),interpretiveerror,communicationfailureorlackofclaritywithrecommendations.Variouscognitiveandsystemfactorscontributetoerrorandanunderstandingoftheseandhowtosafeguardagainstthemcanimprovequalityandreduceerror.WhileimprovementinITundoubtedlyprovideopportunitytoreduceerroralsointroduceotherssuchasvoicerecognitionerror.
Chestimagingisfarfromimmunetoerror.Datafromthe1940sshoweddiscrepancyin10–20%ofCXRreadinginpatientswithsuspectedTB.19%oflungcancerspresentingasanodule(median1.6cm)onCXRaremissedprospectivelywithreportedratesofbetween25and90%beingdescribed.InterpretationoftheprojectionalCXRiscomplicatedbysuperimpositionofstructuresbutthoughcrosssectionalimagingsuchasCTovercomesthiserrorsofdetectionremaincommon.Thisincludesdetectionoflungnodules,pulmonaryemboliandmonkeys.Butdetectionisonlyonepartofthejob,othersincludeinterpretationandcommunication.Ineachelementbothautomaticandsystematicprocessescomeintoplay.
Learningobjectives:• Describecommonexamplesoferror/discrepancyinchestimagingandtheir
prevalence• Identifywhatfactorsmaycontributetothem• Discusshowthesemayinpartbemitigated
Abdominal trauma imagingDr Sara Upponi
Imagingintraumaischallengingowingtoboththepotentialcomplexityofinjuryandnecessityforatimelyreport.DiscrepanciesrelatedtoCTinabdominaltraumawillbepresented.Thesecommonlyincludeinjuriesthatmaybeclinicallyoccultoftenrelatedtothebowelandretroperitoneum.Reportconstructionandcommunicationwithinthewidertraumateamwillbediscussed.
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MSK imagingDr Andoni Toms
ThemostcommoncauseformedicalmalpracticesuitsagainstradiologistsintheUSAisafailuretodiagnoseinthemusculoskeletalsystem.Alargeproportionoftheseareperceptualerrorsinvolvingmissedfracturesormetastases.Scaphoidfracturesareoneofthemostcommonlymissedfracturesbutthefailuretodiagnoseisarguablyasystemfailureratherthanapurelyradiologicalfailure.Failureofinterpretationaccountsforaboutonefifthoferrors.Inthemusculoskeletalsystemtheseofteninvolveover-callingbenigndiseaseasmalignant.Age-relatedfibrofattychanges,andhaematopoesis,inspinalbonemarrowcantriggeradiagnosisofmarrowinfiltration.Inflammatoryspondyloarthropathiescanbemistakenforspinalmetastases.Focalvertebralabnormalitiessuchasaggressivehaemangiomas,andChronicRecurrentMultifocalOsteomyelitisorSAPHOsyndrome,canpresentasfocalmalignancies.
HyperintenseT2Weightedsignalchangesinintervertebraldiscsarenotalwaysassociatedwithinfectionandcalcifictendinopathiesofthespinecanmimicaninfectivediscitis.TheseareundoubtedlyunderdiagnosedbuteasytoidentifywithCT.Heterotopicossificationofsofttissue(formerlyknownasmyositisossificans)isassociatedwithmarkedinflammatorychangesearlyinitsevolutionthataresometimesinterpretedasaggressivesofttissuesarcomas,butcharacteristicfeaturesallowanearlydiagnosis.Similarlyacutecalcificenthesopathiescanpresentwithapparentcorticaldestructionandaggressiveperiostealchangesthatareofteninterpretedascorticalmetastasesorosteogenictumours.
Breast imagingDr Matthew Wallis
Breastimaging/servicesareperceivedtobeamajorsourceofmedico-legalcomplaintsandaresaidtoputtraineesoff.Inrealityerrorsarestressfulbutasanindividualandaserviceareinfrequent.Errorsinscreeningandsymptomaticpracticescanbeclassifiedinthesamewayastherestofradiology:perception,interpretationandprocessandIwillshowexamples.
Theproblemwithscreeningisthatweinvitewellwomenanddespiteallthepublicitythereisstillaperceptionof‘perfection’.Wealsohavelargevolumesofmonitoringdatasowhenthingsgolessthanperfectly‘isthisabadradiologist?’and‘wemuststopthishappeningagain’frequentlysurface.Iwilldiscussthedifficultiesofaddressingthesesortsofquestionswithdatathatisprimarilyservicebasedandisusuallyusedtohelpimproveperformance.
FinallyIwilloffersomepersonalthoughtsonwhatinthe1990sscreeningcalled‘disclosureofaudit’butisnowcalleddutyofcandour.Thereisgoodevidencethatifwe‘breakbadnews’badlythentherearelong-termconsequences,thesameistrueofcandour.Forcinginformation,onsomeonetryingtocometotermswithadiagnosisofcancer,breaksalltheprinciplesofgoodcommunication.
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Paediatric imagingDr Caren Landes
Errorsanddiscrepanciesinpaediatricradiologyareoftenrelatedtoinexperienceandlackofknowledgeofthenormaldevelopmentalanatomy.
Thispresentationwillaimtoraiseawarenessofthemorecommonpitfallsencounteredwheninterpretingpaediatricimagingandwillgiveadviceashowtoavoidthem.
Head and neck imagingDr Elizabeth Loney
Errorsaredeviationsfromthenorm,whethertheyresultinharmornot.Onecouldthinkofthemasfallingintooneof3groups:
• Mis-s:youdidn’tseeanything• Mis-interpretation:yousawsomethingbutinterpreteditincorrectly• Mis-take:yousawsomethingandinterpretedit,butfailedtoappreciateits
fullextentordofurtherappropriateinvestigations
Educationalaims:• Thislecturewilluserealerrorcasescollectedoveranumberofyearsthat
demonstratecommonpitfallsinHeadandNeckRadiology• Foreachcasetheaudiencewillhavequestionsposedandrelevantimages
demonstrated.Participantswillbeabletotestthemselvesastowhethertheywouldhavespottedthepathologyinquestion
• Lessonstobelearntwillbegivenaftereachcase
Reviewareaswillbehighlightedalongwithcommonerrorsmadewhenstagingheadandneckcancers.Ihopethatattendeeswillfeelthatthe‘interactive’natureofthesessionprovidesanopportunityforreflectivelearning.
Learningobjectives:• tobefamiliarwithcommonerrorsinheadandneckradiology.• todevelopasystematicreportingapproachincludingreviewareasinthesame
wayaswhenreportingchestradiographs
Quality assurance in radiology reporting: peer feedbackDr Richard FitzGerald
http://www.rcr.ac.uk/docs/radiology/pdf/BFCR(14)10_Peer_feedback.pdf
Followingthepublicationofthethe1781pagereportofthe2ndFrancisInquiryintotheMidStaffordshireFoundationTrust,containing290recommendations,theHealthSecretaryaskedDonBerwicktoleadanexpertgrouptoproducea
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reportonnextstepstowardabetterandsaferNHS.
Theresultant46pagereport,APromisetoLearn,aCommitmenttoAct:ImprovingtheSafetyofPatientsinEngland–theBerwickReport,had3keypoints:• Theimportanceofsafestaffinglevels• Theneedforlifelonglearningbyallhealthcareprofessionals• “Fearistoxictobothsafetyandimprovement”
TheexcellentRoyalCollegeofRadiologistsRadiologyEventsandDiscrepancies(RCRREAD)publicationsareverymuchinthespiritofBerwickrecommendationsofreducingfearintheworkplaceandlifelonglearning.Promptedbyverylowelectronichitrates,theywillinfuturebepublishedinpaperaswellaselectronically.Pleaseconsidersubmittingcasestoread@rcr.ac.uk.
BerwickrecommendationshavebeenthemajorinfluencingprinciplesbehindtherecentRCRpublicationQualityAssuranceinRadiologyReporting:PeerFeedbackwhichencouragesdailylearningthroughITfacilitated,workflowefficient,supportivetextfeedbackdeliveredtoprimaryreporters.
Whilesomeofthiswouldarisethroughmulti-disciplinaryteamparticipation,andLearningfromDiscrepanciesMeetings,thereisevengreaterpotentialforthisinroutinepracticewhenreviewingpriorimagingandreports.Mosttimesthisfeedbackshouldbequickandbriefe.g.“goodspot”,“seefollowupCT/MRetc”,“pathologyshowedx”,“seeimprovementony”.Inasmallminorityofcases,itwouldbe“whenisagoodtimetodiscussx?”.
Supportivetextfeedbackiswhatitsays.Itisnotdoublereporting,supplementaryreporting,scoringorclassification.ItcanbeamajorcontributortoefficientlifelonglearningforallRadiologists.Reviewaloneisnotfeedback.
CulturechangeaswellasbetterITisrequired.TheBerwickReportstates,“Intheend,culturewilltrumprules,standardsandcontrolstrategieseverysingletime,andachievingavastlysaferNHSwilldependfarmoreonmajorculturalchangethanonanewregulatoryregime”.
Anycyberbullyingshouldbedealtwithusinganorganisation’sBullyingandHarassmentPolicies.Itisenvisagedthatelectronictextpeerfeedbackwill,intime,becomeasroutineforRadiologistsasreviewofrelevantpriorimaging.TheRCRwillauditthisduring2016.
KeyReferences:
Apromisetolearn–acommitmenttoact.ImprovingthesafetyofpatientsinEngland.NationalAdvisoryGroupontheSafetyofPatientsinEngland.August2013.
Rethinkingpeerreview:whataviationcanteachradiologyaboutperformanceimprovement.DBLarson,JJNance.Radiology2011:259:626–632
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Knowledgesharinginradiology.RGunderman,SChan.Radiology2003:229:314–317
Inter-ratervariationinscoringradiologicaldiscrepancies.BMucci,HMurray,ADownie,KOsborne.The British Journal of Radiology 2013.doi.10.1259/bjr20130245
Inter-rateragreementintheevaluationofdiscrepantimagingfindingswiththeRADPEERsystem.LCBenderetal.Am J Roentgenol2012:199:1320–1327
Peerreviewcommentsaugmentdiagnosticerrorcharacterisationanddepartmentalqualityassurance:1yearexperiencefromachildrenshospital.RSIyeretal. Am J Roentgenol2013:200:132–137
Commentaryondiscrepanciesindiscrepancymeetings.PMcCoubrie,RFitzGerald.Clinical Radiology2014:69:11–12
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