radiology errors

The journey from research to publication14 November 2013

Venue: British Dental Association

5 CPD credits

Radiology errors31 January 2014

Venue: The Holiday Inn - Bloomsbury

5 CPD creditsRegistered Charity No: 215869

Welcome and thank you for coming to ‘Radiology errors’ event organised by the British Institute of Radiology.

This booklet contains the abstracts and biographies for each speaker (where supplied).

This meeting has been awarded 5 RCR category I CPD credits. CPD certificates will be distributed by email within two weeks of the meeting once the online delegate survey has been completed.

Please complete the online delegate survey using the below link. We will use your valuable feedback to improve future conferences.

https://www.surveymonkey.com/s/radiology_errors

We hope you find the day interesting and enjoyable.

DR Teik Choon See,Meeting organiserConsultant Radiologist, Addenbrooke’s Hospital

for supporting this event

We are most grateful to

PROGRAMME

09:00 Registration and refreshments

Chair: Dr Teik Choon See, Consultant Interventional Radiologist, Addenbrooke’s Hospital

09:30 Welcome and introduction

09:35 Advantages and disadvantages of radiological discrepancy scoring Dr Richard FitzGerald, Consultant Radiologist, The Royal Wolverhampton Hospitals NHS Trust

10:05 Systematic improvement following discrepancy meetings Dr Teik Choon See, Consultant Interventional Radiologist, Addenbrooke’s Hospital Dr Sara Upponi, Consultant Radiologist, Addenbrooke’s Hospital

10:35 Implementing human factors in a radiology department Dr Jane Carthey, Human Factors and Patient Safety Consultant, Clinical Human Factors Group

11:05 Refreshments

11:25 Medico-legal risks for radiology Dr Shawn Halpin, Consultant Neuroradiologist, University Hospital of Wales

11:55 Errors in abdominal radiology – what, why and how not to Dr Helen Bungay, Consultant Gastrointestinal Radiologist, Oxford University Hospitals NHS Trust

12:25 Lunch

Chair: Dr Sridhar Redla, Consultant Radiologist, Princess Alexandra Hospital

13:15 Thoracic imaging Dr Anu Balan, Consultant Thoracic Radiologist, Addenbrooke’s Hospital

13:45 Neuroradiology Dr Daniel Scoffings, Consultant Neuroradiologist, Addenbrooke’s Hospital

14:15 Missed breast cancers Professor Alastair Gale, Professor of Applied Vision Sciences, Loughborough University

14:45 Refreshments

15:00 MSK imaging Dr Melanie Hopper, Consultant Radiologist, Addenbrooke’s Hospital

15:30 Interventional radiology Dr Raman Uberoi, Consultant Radiologist, John Radcliffe Hospital

16:00 Managing radiological performance in teleradiology Dr Stephen Davies, Consultant Radiologist, Royal Glamorgan Hospital and Medical Director, Medica Reporting

16:30 Close of meeting_______________________________________________________________________

Please remember to complete the online delegate survey using the below link:


Your certificate of attendance will be emailed to you within the next two weeks once these have been completed.

Speaker profiles (where supplied)

Dr Helen BungayConsultant Gastrointestinal Radiologist, Oxford University Hospitals NHS Trust

Having been educated at St John’s College, Cambridge and Green College, Oxford, I commenced as a specialist Gastrointestinal Radiologist with the OUH NHS Trust in 2000. I am the Lead Hepatobiliary Radiologist, and work closely with my excellent GI colleagues. I have published on small bowel imaging, minimal preparation CT colons, primary sclerosing cholangitis, amongst others. I have given invited lectures in recent years at RSNA, UKRC, the RCR, BIR and BSGAR, on topics such as US of the Gall Bladder, MRCP, and IgG4 related disease.

Dr Jane CartheyHuman Factors and Patient Safety Consultant, Clinical Human Factors Group

Dr Jane Carthey is a Human Factors Specialist and former Assistant Director of Patient Safety at the NPSA. Dr Carthey has worked as an independent Human Factors Consultant since 2005, providing human factors consultancy services to a range of clients including UCLH NHS Hospitals Foundation Trust, Great Ormond Street Hospital NHS Foundation Trust and The Royal Pharmaceutical Society of Great Britain. She is co-author of the Health Foundation report ‘Measuring and monitoring patient safety’ alongside Professor Charles Vincent and Susan Burnett.

Dr Stephen Davies, Consultant Radiologist, Royal Glamorgan Hospital and Medical Director, Medica Reporting

Dr Stephen Davies MA FRCP FRCR is a Consultant Radiologist practicing in Cwm Taf Health Board and is Medical Director of Medica Reporting. He was President of the British Institute of Radiology 2010-2012, UKRC President for 2008 and 2009 Congresses, Associate Dean and Head of Radiology School in Wales (2005-2011) and Quality Assurance Lead for Education for the Clinical Radiology Faculty at the RCR 2010-2012. He is a Musculoskeletal Radiologist and is an accredited Expert Witness.

Dr Richard FitzGeraldConsultant Radiologist,The Royal Wolverhampton Hospitals NHS Trust

Elected Member, Royal College of Radiologists Professional Support and Standards Board 2011-

Vice-President elect Royal College of Radiologists. Term of office September 2014-

Member, Management in Radiology Subcommittee, European Society of Radiology, 2010-

Lectures given on Radiologist Regulation and Performance in the USA, Australia, Austria, Denmark, France, Hungary, Ireland, Italy, Latvia, Spain, Sweden, and at various centres around the UK.

General Medical Council Radiologist Assessor for Professional Performance Procedures, 2002 –2013.

I have mentored radiologists and other doctors in difficulties over the past 17 years.

Publications :

Commentary on discrepancies in discrepancy meetings. P McCoubrie, R FitzGerald. Clinical Radiology 2014 ; 69 : 11-12.

Commentary on: Workload of Consultant Radiologists in a large DGH and how it compares to international benchmarks. R. FitzGerald. Clinical Radiology (2013) ; 68 : e237-e238.

Commentary on the impact of teleradiology in the United States over the last decade: driving consolidation and commoditisation of radiologists and radiology services. R. FitzGerald . Clinical Radiology (2009) 64 , 461-462.

Medical regulation in the telemedicine era. R FitzGerald. Lancet (2008) ; 372 : 1795-1796.

Radiological error: analysis, standard setting, targeted instruction and teamworking. R.FitzGerald. European Radiology (2005) 15 ; 1760-1767.

Error in Radiology. R.FitzGerald. Clinical Radiology (2001) 56 ; 938-946.

How accurate is cancer scan reporting? R. FitzGerald and R. Mehra. Hospital Medicine (2000) 61 ;637-642.

Professor Alastair GaleProfessor of Applied Vision Sciences, Loughborough University

Alastair is Professor of Applied Vision Sciences at Loughborough University where he heads a research centre investigating human performance in various scenarios. He has been involved in radiological research for 40 years and with the breast screening programme since its inception.

Dr Shawn HalpinConsultant Neuroradiologist, University Hospital of Wales

I qualified at King’s London, and after gaining MRCP, joined the St George’s radiology training scheme. Since 1993, I have been a Diagnostic and Interventional Neuroradiologist in Cardiff. I have been interested in medical errors for some time, and completed a Masters degree in Law in 2009, writing my dissertation on the interface between error and negligence in radiology.

Dr Sridhar RedlaConsultant Radiologist and Clinical Director - Cancer, Diagnostics and Pharmacy, The Princess Alexandra Hospital NHS Trust

I trained in Hammersmith Hospitals, London, and obtained my FRCR in 1998.I took up my Consultant post in Princess Alexandra Hospital, Harlow in November 2000.I was the College Tutor and a member of the East of England Radiology Training Committee between 2004-07.I was the Lead Radiologist at PAH, Harlow between 2007-2011.I am presently the Clinical Director for Cancer, Diagnostics and Pharmacy at the same hospital (since Jan 2012).I joined the Clinical Imaging Committee of the BIR in 2008-09 and took over as the Chair of the reconstituted Clinical Imaging Special Interest Group (SIG) in 2012.

Dr Daniel ScoffingsConsultant Neuroradiologist, Addenbrooke’s Hospital

I trained in radiology in Leeds and neuroradiology in Cambridge before being appointed as a Diagnostic Neuroradiologist in 2008. I have subspeciality interests in head and neck imaging, stroke and CT-guided spinal interventions. I have published peer reviewed articles and authored several book chapters and I am an advisory editor for the journal Clinical Radiology.

Dr Teik Choon See Consultant Interventional Radiologist, Addenbrooke’s Hospital

Dr See is a Consultant Interventional Radiologist at Addenbrooke’s Hospital, Cambridge. His special interests include hepato-biliary interventions and interventional oncology. He is actively involved in clinical governance, management of radiology errors and quality improvement locally and nationally. He chaired the BIR East of England branch since its inception in 2010 to 2013. He initiated a number of local, regional and national educational events related to interventional radiology, patient safety and the Cambridge FRCR course.

Dr Raman UberoiConsultant Radiologist, John Radcliffe Hospital

Qualified at Cambridge university 1985.Consultant IR Radiologist 18 years.Based at the John Radcliffe HospitalSenior Lecturer.Vice president of the BSIR.Professional Standards Board RCR.

Dr Sara UpponiConsultant Radiologist, Addenbrooke’s Hospital

I am a Consultant Radiologist at Addenbrooke’s Hospital, Cambridge. I undertook my registrar training in Oxford, followed by a fellowship in abdominal imaging at the University of Michigan, Ann Arbor USA. I have been co-lead for our local discrepancy meeting for the past 5 years. My interests are in abdominal and trauma imaging.

Abstracts (where suppiled)

Advantages and disadvantages of radiological discrepancy scoringDr Richard FitzGerald

Radiologist scoring of reporting discrepancies has been shown to be inconsistent in recent research from Glasgow and Seattle. [1,2]This is not surprising given the many biases in such activity ,[sampling, selection, presentation, information, hindsight, outcome, attendance, variation]. Lesion conspicuity varies due to patient or technical factors etc etc. Detection as well as judgement depends on clinical information available at time of reporting.Most Radiology reporting is not a binary activity.Commercial bias could arise is scoring ….. imagine Ryanair being asked to score BA performance or vice versa?!Scoring uses up precious knowledge sharing time at quality improvement [discrepancy] meetings and during electronic feedback. [3, 4] Why score? To what end? Peer reviewed published literature does not exist to show any service improvement from radiologist scoring of reporting discrepancies.A scoring culture can fuel a blame culture with less collective learning from errors/discrepancies/near misses. [5] This has adverse risks and consequences for patients, teamworking, and service improvement .The Berwick Report describes fear as toxic to patient safety and improvement. It emphasises a learning culture, not a scoring culture. [6]“For staff, fear is becoming the prevailing culture in the NHS” ……”doctors face humiliation and shame for any transgression” C Gerarda et al in a recent publication from the practicioner health programme . [7]“Peer review can serve either as a coach or a judge, but it cannot successfully do both at the same time (and it has not been shown to do the latter well very well in any case” DB Larson et al [8]In short radiologist scoring of reporting discrepancies is not recommended as a method of improving our performance for patients [9, 10]

References:

[1] Inter-rater variation in scoring radiological discrepancies. B Mucci, H Murray, A Downie, K Osborne BJR 2013 doi.10.1259/bjr20130245.

[2] Inter-rater agreement in the evaluation of discrepant imaging findings with the RADPEER system. LC Bender et al AJR 2012 ; 199 : 1320-1327.

[3] Discrepancies in Discrepancies Meetings. Results of the UK National Discrepancy Meeting Survey. SJ Prowse, B Pinkey, B Etherington. Clin Radiol 2014 ; 69 : 18-22.

[4] Peer Review Comments Augment Diagnostic Error Characterisation and Departmental Quality Assurance: 1 Year Experience From a Childrens Hospital. RS Iyer et al AJR 2013 ; 200 : 132-137.

[5] Focused Peer Review : The End-Game of Peer Review. S Hussain et al J Am Coll Radiol 2012 ; 9 : 430-433.

[6] A promise to learn- a commitment to act. Improving the safety of patients in England. National Advisory Group on the Safety of Patients in England. August 2013.

[7] Young female doctors, mental health and the NHS working environment . C Gerarda et al BMJ Careers 11 January 2014, p3-4.

[8] Rethinking Peer Review: What Aviation can Teach Radiology about Perfor-mance Improvement . DB Larson, JJ Nance. Radiology 2011 : 259 : 626-632.

[9] Commentary on discrepancies in discrepancy meetings. P McCoubrie , R FitzGerald. Clin Rad 2014 ;69 : 11-12.

[10] 8 CT lessons that we learned the hard way : an analysis of current patterns of radiological error and discrepancy with particular emphasis on CT. G McCreadie, TB Oliver. Clin Radiol 2009 ; 64 : 491-499.

Systematic improvement following discrepancy meetingsDr Teik Choon SeeDr Sara Upponi

The value of discrepancy meetings is to identify and share learning with the aim of improving the quality and standard of our services. There are a number of improvement strategies, ranging from individual effort to systemic collaboration and organisational transformation. Our experience denotes that positive changes are more effective when these are conducted in multiple small scale activities with the aim of achieving a specific outcome. Improvement can only be realised by a continuing process of re-evaluation all of which will contribute to enhance accountability and quality of our services. One example of making positive changes is through the process of identifying risks and improvement strategies according to patient pathway.

Implementing human factors in a radiology departmentDr Jane Carthey

Human factors encompass all those factors that can influence people and their behaviour. In a work context, human factors are the environmental, organisational and job factors, and individual characteristics which influence behaviour at work (Clinical Human Factors Group, 2009). Other industries, like nuclear power generation, off-shore oil and gas production have long realized the benefits of using human factors science in the design and management of systems.Similarly, healthcare systems, including radiology departments, equipment and work patterns, need to be designed to take account of human cognitive strengths and weaknesses.

The presentation will provide an overview of the discipline of human factors and discuss how human factors principles have been applied to prevent harm to patients in various healthcare settings. The potential to apply human factors in a radiology department and what this might involve will also be discussed. This will involve consideration of the leadership, teamwork, task, environmental and organisational challenges that radiologists face and how applying human factors science could help to overcome them.

Medico-legal risks for radiologyDr Shawn Halpin

Radiology errors are common, and a cause of morbidity, mortality, and accusations of negligence. In order to understand errors, one must first understand expertise. Expertise lies is a semi- or sub-conscious state of mind, and is gained by endless repetition of the same routines: not just in the reporting of images, but in the daily processes of reporting. The commonest cause of perceptual error is interruption. Recent changes in the law have made it more likely that an accusation of negligence will be successful. Although there is legal precedent that states that errors can be regarded as non-negligent, in daily practice any error that results in patient harm may well be judged harshly.

Errors in abdominal radiology – what, why and how not toDr Helen Bungay

Educational aims:1. To start to think about radiological error in a structured manner2. To become cognisant of potential sources of error3. To be familiar with never events as applied to abdominal imaging4. To examine psychophysiological factors affecting performance5. To consider ways to reduce error

Learning outcomes:To be conversant with types and causes of error and what practicing radiologists might be able to do to minimise these

Thoracic imagingDr Anu Balan

To provide an overview of how and why thoracic discrepancies occur, with illustrations of different types of error. Examples of chest x-ray and chest CT imaging will be given, looking at a broad spectrum of ‘misses’, and in particular at frequent sites of error, review areas and an approach on how to minimise errors.

NeuroradiologyDr Daniel Scoffings

This talk will briefly review the published work on neuroradiology errors before presenting a series of illustrative cases derived from the speaker’s review of on-call reports.

Missed breast cancersProfessor Alastair Gale

Educational aims: To understand the nature of radiological errors in breast screening.

Learning outcomes: To comprehend the advantages and limitations of using tests sets to measure radiological performance.

Skilled radiological performance can be understood in two ways: how well someone identifies abnormalities correctly and how well they agree with colleagues on radiological outcomes. Various performance measures can be utilised such as; sensitivity, specificity, ROC scores, abnormality detection and radiological feature classifications. Understanding performance is more complex in screening situations, such as in breast radiology, where in real life the abnormality incidence is very low and so it can be difficult to gauge an individual’s skill level. One way to assess skilled performance in screening then is to use test sets of carefully selected exemplar images.Illustrations will be presented from the use of the PERFORMS self-assessment scheme which is used nationally in breast screening. In this, individuals examine sets of recent challenging screening cases and receive immediate detailed feedback as well as subsequent feedback where their performance is anonymously compared to colleagues.

The scheme identifies individuals who are under-performing, the underlying reasons for their performance can be determined and improvement strategies proposed for them to follow. However, care must be taken in interpreting the results of such sets as the individual knows it is a test, the sets are usually weighted with abnormal and possibly rare cases – all factors which affect any performance measures. The PERFORMS scheme is available internationally as well as being rolled out across other radiological domains. Overall it is argued that screening performance test sets, are a very useful educational exercise as well as an external quality assurance tool.

Interventional radiologyDr Raman Uberoi

Learning objectives: 1. To understand the importance of pre-procedural planning.2. To routinely carry out peri-procedural checks using the ‘Radiology NPSA’ checklist.3. Importance of learning from mistakes.4. Importance of familiarity with the equipment.

The level of error being reported nationally within radiology most likely comprise only a tip of the iceberg. Complacency in daily routine procedures can easily result in patient harm often for the daftest reasons. Any procedure that requires needle insertion for the purposes of diagnostic or therapeutic procedures has the potential for catastrophic consequences. Errors occur in all medical practice and it is important for all health professionals to learn from these mistakes that may occur. This is no more important than in interventional radiology. It is clear that significant errors occur in interventional radiology despite many safeguards. Pre-procedural planning with good patient selection, in the correct enviroment, ensuring familiarity with all the key equipment as well as good training are vital to ensuring the right outcome for the patient. A team approach to managing patients with involvement of all the key staff taking responsibility for the patient is also key to improving patient safety. Pre, peri and post procedural checks can also help reduce mistakes. The NPSA/RCR checklist is a simple tool that can help avoid errors adding only a few minutes for complex procedure and even less for more simple procedure. We have a duty of care to our patients to do no harm and the checklist is a simple tool which can help us deliver this, so let’s use it.

Managing radiological performance in teleradiologyDr Stephen Davies

Aim of presentation: To consider the process for identification and management of concerns regarding radiologist performance in teleradiology.

Outcomes:1. To describe factors influencing radiologist performance.2. To describe the proactive and reactive quality assurance processes monitoring radiologist performance.3. To consider methods to evaluating concerns.4. To consider a learning culture approach to managing performance.

Reading:

Bender, L. C., Linnau, K. F., Meier, E. N., Anzai, Y., & Gunn, M. L. (2012). Interrater agreement in the evaluation of discrepant imaging findings with the Radpeer system. AJR Am J Roentgenol, 199(6), 1320-1327. doi: 10.2214/AJR.12.8972.

Larson, D. B., & Nance, J. J. (2011). Rethinking peer review: what aviation can teach radiology about performance improvement. Radiology, 259(3), 626-632. doi: 10.1148/radiol.11102222.

McCoubrie, P., & Fitzgerald, R. (2014). Commentary on discrepancies in discrepancy meetings. Clin Radiol, 69(1), 11-12. doi: 10.1016/j.crad.2013.07.013.

Prowse, S. J., Pinkey, B., & Etherington, R. (2014). Discrepancies in discrepancy meetings: Results of the UK national discrepancy meeting survey. Clin Radiol, 69(1), 18-22. doi: 10.1016/j.crad.2013.05.105._______________________________________________________________________

Please remember to complete the online delegate survey using the below link:


Your certificate of attendance will be emailed to you within the next two weeks once these have been completed.

Our platinum sponsors

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radiology errors

Documents

consultant neuroradiologist

radiology dr shawn halpin

dr sridhar redla

dr richard fitzgerald

patient safety consultant

addenbrookes hospital13

thoracic imaging dr

addenbrookes hospital14