ACR Bulletin

Covering topics relevant to the practice of radiology

Learning From Mistakes

The vice chair of the Commission on Quality and Safety discusses the critical role of just culture and peer learning in improving Q&S — without judgment or blame.
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A lot of judgment among peers in medicine ends up working against what we want to promote, which is collegial, close working relationships.

December 01, 2020

The effectiveness of a radiology quality and patient safety program is enhanced by an ongoing understanding of prevailing errors. Many tools are available to assist in analyzing errors and understanding their cause, but this understanding cannot happen unless errors are revealed in the first place. Staff members are often reluctant to reveal their own or others’ mistakes if they fear adverse consequences or potential disciplinary action. Unfortunately, this is the case in many practices today. Although adverse events may ultimately come to light when patient harm occurs, even under those circumstances, less consequential errors or near misses may remain hidden, and future patients remain at risk.1

A just culture is an environment in which errors and near-miss events are evaluated in a deliberately nonpunitive framework, avoiding a culture of blame and responsibility and focusing instead on error prevention and fostering a culture of continuous quality improvement. Adoption of a just culture requires careful attention to detail and relies on continuous coaching of individuals and teams to build a culture of safety.2 In a recent interview, Jennifer C. Broder, MD, vice chair of the ACR Commission on Quality and Safety (Q&S) and vice chair of Q&S at Lahey Hospital and Medical Center’s department of radiology in Burlington, Mass., shared her insight on why it is important to build a just culture, and how peer learning is an expression of just culture for radiologists.

What is just culture and how does it work?

The most important part of improving Q&S in your practice is to establish a just culture — where people can trust their errors will be treated fairly and humanely. At Lahey Hospital and Medical Center, we have been working for several years to implement a just culture model, which is a method of investigating why errors happen and how to address them in a consistent, fair, and transparent way. This model is used to review errors across all aspects of our work in the department, from administrative to clinical.

The just culture method directs management through a set of guiding questions to determine the underlying causes of an unfavorable event: Was the mistake the result of human error, at-risk behavior, or reckless behavior? Once we determine the intent behind the person’s actions, the model outlines appropriate responses for each scenario. Human error results in consolation, at-risk behavior results in coaching, and reckless behavior results in disciplinary action.

While it is more challenging to apply an algorithmic approach to reviewing interpretive errors — rather than, for instance, errors in RT workflow — the tenets of a just culture establish the ground rules for our peer learning program. Peer learning is, in essence, the manifestation of a just culture for our clinical work.

How would you describe peer learning?

A new paradigm for peer review has emerged, peer learning, which is a group activity in which expert professionals review one another’s work, actively give and receive feedback in a constructive manner, teach and learn from one another, and mutually commit to improving performance as individuals, as a group, and as a system. Many radiology practices are beginning to transition from score-based peer review to peer learning.3 By avoiding judgment and focusing on learning, we   collegiality and collaboration that, in turn, fosters a culture of learning and improvement.

The primary benefit of peer learning is that it cultivates an environment in which we’re all working together to learn without judgment. The beauty of a well-functioning peer learning system is that everyone in the practice understands it’s their responsibility to help their peers learn and improve, and they don’t mind doing it because it helps build relationships and improve their own practice as well. In practices with robust peer learning programs, we not only learn from our mistakes, we also identify times when people do a great job and help everyone else learn from that experience. I call it “learning from the masters” — we use the opportunities when people are really doing well to help everyone else learn how to succeed in the future.

Beyond individual and group learning, the second major benefit of peer learning is that a well-organized program will consistently find ways to translate learning opportunities into systems improvements. For example, at our institution the review of one neuroradiology case led to the creation of a hospital-level diagnostic pathway involving multiple disciplines.

The value of peer learning is that it allows people to focus on how to improve without the negative side effects of judgment or blame.

Why has peer learning come more to the forefront in Q&S?

The value of peer learning is that it allows people to focus on how to improve without the negative side effects of judgment or blame. Medicine is traditionally set up to review each other’s work with a heavy hand. Many people who come into medicine are perfectionists, and we take great pride in our work. When judgment is associated with times we haven’t succeeded, it results in shame. That shame has two consequences. One: It makes people feel terrible, which really destroys an opportunity for learning. We all know that we don’t learn well when we are shrouded in negative feelings. Two: It makes other people not want to bring up mistakes, errors, or opportunities for improvement, because we don’t want to make each other feel bad.

A lot of judgment among peers in medicine ends up working against what we want to promote, which is collegial, close working relationships. To achieve the most benefits from peer learning programs, to create highly functional collegiality, it’s critical to eliminate all opportunities for peer-to-peer judgment. It’s also important to note that a key starting point for peer learning is to establish a just culture.

How can radiologists become more engaged in peer learning?

One of the most exciting initiatives of the ACR Commission on Q&S is the new Peer Learning Committee, in which we will be working to help more practices establish peer learning programs. We’re developing the Peer Learning Committee in response to the growing momentum across the country and internationally among practices to implement peer learning. The goal of the committee is to look at what’s being done, establish best practices, and define what constitutes a rigorous peer learning program. Then we’ll work to support implementation of new peer learning programs across varied types of radiology practices through education, outreach, and mentorship. Eventually, we hope to coordinate formal adoption of peer learning as a pathway for peer review in the accreditation process.


1. 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.
2. Burns J, Miller T, Weiss JM, Erdfarb A, Silber D, Goldberg-Stein S. Just Culture: Practical Implementation for Radiologist Peer Review. J Am Coll Radiol. 2019;16(3):84–388.
3. Larson DB, Broder JC, Bhargavan-Chatfield M, Tan N, Siewert B, Kruskal JB. Transitioning From Peer Review to Peer Learning: Report of the 2020 Peer Learning Summit. J Am Coll Radiol. 2020;17(11):1499–1508.

Author Interview by Linda Sowers, freelance writer, ACR Press