ACR Bulletin

Covering topics relevant to the practice of radiology

Make No Mistake

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Less fear and more conversation could mean better medical error rates.

Every medical professional I know is doing the best job they can in what are often very stressful situations.

—Stephen A. Waite, MD
December 01, 2019

Understanding that to err is human does not give radiologists a pass on medical errors. It can, however, shift a mindset of failure to a renewed focus on creating an environment in which physicians support and learn from one another — where individuals contribute to the collective standards of their healthcare team, while raising the bar for patients who rely on their commitment and expertise.

“No physician wants to make a mistake. And while you can’t eliminate all errors, no individual error is unavoidable,” says Paul L. Epner, MBA, MEd, CEO and co-founder of the Society to Improve Diagnosis in Medicine (SIDM). Success in reducing diagnostic errors in radiology, he says, does not lie in presuming that a certain level of errors is intrinsic to the system.

The National Academy of Medicine (formerly the Institute of Medicine) defines diagnostic error as a failure to establish an accurate and timely explanation of a patient’s health problem(s), or to communicate that explanation to the patient. While the error rate for radiologists is lower than that of other specialties — internal medicine, pediatrics, and emergency medical care, as examples — the fact that millions of imaging exams are performed each day in the U.S. puts radiologists in an unenviable position.1

There are, of course, other failings that do not fall within diagnostic interpretive errors — such as the ordering of inappropriate studies, PACS failures, a lack of accurate clinician contact information, incomplete medical records, or hazards inherent to IR. These all lead to wasted resources, delays in patient care, and potential negative outcomes.2 There is no arguing, however, “mistakes relating to diagnosis are the most common, most catastrophic, and most costly of all medical errors,” Epner says.

In radiology, Epner stresses, interpretation skills are not solely responsible for diagnostic errors. “There are cultural issues associated with the institution as well as demands on time and what gets prioritized,” says Epner. “You have to overlay radiologists’ heavy volume, limited time, lack of proximity to colleagues, and a lack of supporting tools for collaboration.”

Just Culture

Radiology managers must acknowledge the factors that contribute to diagnostic errors to foster a culture that encourages timely and accurate reporting, peer learning, and follow-up measures to prevent future occurrences. The term “just culture” embodies an environment in which errors are evaluated in a non-punitive framework — one that focuses on error prevention and quality improvement rather than finger-pointing and individual accountability (see more on page 4).

Just culture recognizes that adverse events, systems failures, flawed workflow processes, and increased volume all contribute to human error. “Leaders must work to change conditions that promote errors by decreasing distractions, streamlining workflow processes, optimizing PACS/EMR integration and ergonomics, and advocating for streamlined critical results solutions,” suggests Stephen A. Waite, MD, associate professor of radiology with SUNY and NYC Health & Hospitals in Brooklyn.

While there are tools available to assist in analyzing errors and how they occur, these become useless if errors are never revealed. Staff are often reluctant to report their own mistakes or those of coworkers. Some may doubt it will ultimately help anything or anyone. Hesitation may stem from a fear of disciplinary action, intimidation by an entrenched hierarchy, a negative impact on performance reviews, or the possibility of litigation.3

“A punitive culture — the traditional medical culture where we blame individuals for human mistakes — clearly leads to covering up mistakes,” Waite says. “When they can’t be covered up, a punitive system advocates for punishing individuals for system inefficiencies and understandable mistakes.”

Mistakes can be categorized in three ways: human error, at-risk behavior, and reckless behavior.4 In a just culture framework, Waite says, punishment is recommended only for reckless behavior and a conscious disregard for a substantial and unjustifiable risk.5 “I think such an occurrence is exceedingly rare,” says Waite. “Every medical professional I know is doing the best job they can in what are often very stressful situations.”

Peer Learning

Contrary to a punitive environment that can erode radiologists’ confidence and potentially make them question their own interpretive skills, peer learning creates opportunities to improve individual performance, the organization, and the entire culture of safety.

“Peer learning moves away from the judgment of standard peer review,” says Jennifer C. Broder, MD, vice chair of radiology quality and safety at Lahey Hospital and Medical Center in Burlington, Mass. In standard peer review, a radiologist might review a certain number of cases each month, scoring them on a 1 to 3 ranking system, Broder notes. One is seen as the best score, and 3 the worst, as the language used to describe the ‘3’ implies the mistake should not have been made by your colleagues.

“Think about how scoring could make you feel about yourself, or your colleagues, or about making mistakes in general,” Broder says. “Scoring systems make people feel judged. We’re already our own worst critics, and scoring can cause worry over implications for your performance evaluations.”

In a peer learning system, the goal is more about identifying learning opportunities rather than grading performance. “It allows people to submit cases with any sort of error when they find them, without judgment,” Broder says. “That feedback goes back to the initial radiologist and also to a section head who can decide if there is value in sharing the case with the larger group.”

According to Broder, peer learning cases may be presented in an educational setting, with a moderator leading discussion. The goal is to help others avoid similar mistakes in similar situations, not to score someone’s efforts or keep count of the number of mistakes. While there may be disagreement during the discussion, the conversation focuses on moving toward improvement. Further, most peer learning programs include opportunities to identify “great calls.” “One person’s great call might have been my miss. These are opportunities to learn from the masters and elevate everyone’s practice,” Broder says.

Collegial Experience

When thinking about reducing interpretive errors, think about prevention, Broder says. “Look at your reading environment and how and where someone is working,” she says. Consider fatigue and long hours as drivers of mistakes. Find out how often interruptions are happening, she says. Personal interaction with clinical coworkers can be invaluable, but the more interruptions, the more likely someone is to make a mistake. Phone calls from people asking questions about other exams can be distracting, and having dedicated staff to filter and triage calls is one solution.

A high volume of reads is always challenging — in terms of accuracy and for accomplishing non-interpretive tasks. “While opinions vary on whether or not faster readers make more mistakes, you still need to look at the experience level of someone who has a heavy workload — especially for certain diagnoses,” Broder notes.

“Gaining experience is absolutely the most important thing in building expertise,” Broder says. And one-on-one interactions are critical, she adds. This could mean learning from another clinical specialist about how they treated a finding, following up on your own notes about a patient, or contacting another radiologist who has more experience in a particular area. For younger radiologists especially, reviewing cases with more seasoned colleagues can be invaluable, she says.

It is incumbent on radiology managers to evaluate if staff have adequate time to follow up on clinical outcomes, opportunities to work alongside other members of the healthcare team, and sufficient administrative support to help them achieve closed-loop communication of results. “Radiologists are sometimes held liable for falling short of communication that someone else thought was important enough to warrant additional communication beyond the report,” Broder says. “Someone may ask, ‘You didn’t think this was important enough to pick up the phone and talk to the other clinician about it?’” The consequences in those types of situations can be significant for all parties involved, she says.

To deny and defend mistakes is never the right way to approach medical errors.

—Susan E. Sheridan, MIM, MBA, DHL

 

Patient Message

Few patients expect absolute perfection from their physicians, but honesty and truthfulness in reporting will advance relationships between physicians and patients for quality patient care.6 Patients and their families impacted by medical errors can experience overwhelming frustration, anger, and loss of trust in their healthcare providers.

“To deny and defend mistakes is never the right way to approach medical errors,” says Susan E. Sheridan, MIM, MBA, DHL, director of patient engagement for SIDM. Sheridan’s son still lives with the effects of permanent brain damage as the result of MRI findings deemed insignificant in the radiology report. Those findings were never communicated to Sheridan or her husband, though they had serious concerns about their son’s health. Her husband died some years later following surgery to remove a tumor. The pathology report was filed without the surgeon seeing it — and once again, the family wasn’t told, this time about the malignant pathology.

In the cases of both her son and husband, Sheridan says not knowing what was happening with test results — because they were not easily accessible and were not revealed quickly enough — led to irreparable damage. “Based on my experience, I would want to know right away if something was suspected. I would rather the medical team come to me and say, ‘We saw some things on MRI that concern us.’ It’s when you find out later that they knew something and it wasn’t disclosed, that breaks the trust,” she says.

It is a fallacy, Sheridan believes, that patients and their families do not want to know about a possible mistake. “It’s all about getting the patient the best outcome possible — not to just check boxes — and to resolve errors in a human and empathic way,” she says.

By approaching the goal of fewer errors as a way to gain the trust of your patients and build stronger relationships with clinical colleagues, radiologists can affect change beyond interpreting images. “People realize that doctors aren’t perfect,” Epner says. “But healthcare leaders should realize that genuine problem-solving means creating an environment in which physicians can talk openly about reducing the likelihood of something bad happening again.” 

ENDNOTES

1. Bruno MA. Error and uncertainty in diagnostic radiology. Oxford University Press; 2019.
2. Waite S, Scott JM, Legasto A, Kolla S, Gale B, Krupinksi EA. System error in radiology. Am J Roentgenol. 2017;209(3):629-639.
3. Broder JC, Doyle PA, Kelly L, Wald C. How we do it: operationalizing just culture in a radiology department. Am J Roentgenol. 2019;213:986-991.
4. Harvey HB, Sotardi ST. The just culture framework. J Am Coll Radiol. 2017;14(9):1239-1241.
5. Abujudeh HH. Just culture: is radiology ready? J Am Coll Radiol. 2015;12(1):4-5.
6. Barron BJ, Banja J. Radiologic reporting: the ethical obligation of the interpreting physician to provide an accurate report. Am J Roentgenol. 2013;201(2):356-360.

Author Chad Hudnall  senior writer, ACR Press