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

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Yourcertificateofattendancewillbeemailedtoyouwithinthenexttwoweeksonceyouhavecompletedtheonlineeventsurveyat:

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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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