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Lessons Learned from the Aviation Industry: Incorporation of Near Miss Reporting into Neuroradiology Resident Education eEdE-210-4110 Michael T. Starc MD, Anjali Shah MD, Nolan Kagetsu MD Mount Sinai St. Lukes-Roosevelt

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No disclosures

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Purpose: 1.Define the Near Miss First illustrated in the aviation industry Recall proven benefits from analyzing near miss safety data 2.Explain how our institution incorporates near miss data Neuroradiology focused resident case-based conference Provide illustrative example cases 3.Describe importance of this near miss resident data Proactive quality improvement and education Recognize early mistakes as true learning opportunities Becoming more relevant in the era of 24/7 attending coverage

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Warm up example: the typical near miss Attending over-read @6 am HYDROCEPHALUS ER notified, patient referred appropriately (Phew!) Donenext case? Or can we learn more from this 28 year old with headache Resident Prelim @5:30am No bleed, mass, or infarct Abnormally dilated temporal horns, effaced sulci and cisterns

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Approach: Lessons from Aviation How? Mechanical innovation But also Improved human performance 6 Learn quickly from mistakes Errors are predictable System based defenses can prevent Identify systems problems vs. unique individual operator failures Increased error reporting near miss error reporting Aviation has evolved from a daredevil pursuit into an extremely low-risk everyday activity Fatal accidents now occur in fewer than 1 in 9 million departures since 2001. 9

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Origins of Near Miss reporting: TWA Flight 514 Upon review, multiple pilots had previously noted confusion with the Tower at Dulles Airport some avoided crash by only dozens of feet Information was not shared from these Near Miss encounters Boeing 727 to Dulles Airport December 1 st, 1974 Tower directive: CLEARED FOR APPROACH Captain interpreted as permission to descend Crashed into 1750 foot hill 92 deaths, no survivors

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TWA Flight 514 (click to advance) Cockpit voice recorder: 8

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Near Miss: Definition An unplanned event that has the potential to result in injury, illness or damage; however, a fortunate course of events prevents damage. 5 Aka a close call Following TWA 514, The FAA established the Aviation Safety Reporting System to confidentially collect, distribute and analyze near miss data. 1,6 Decrease in accidents thanks to improved error reporting. 9 Near Miss reporting has since been applied to many high reliability fields Fire Safety Nuclear Power Chemical Processing Rail travel Health Care, i.e. VA Patient Safety Reporting System

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Error Reporting in Radiology Residency Radiology residents inherently do not have the level of expertise of an expert errors are inevitable. Residency must balance opposed goals. Allow resident independent decision-making Ensure highest quality expert patient care Resident errors are rare but can be clinically important. 10 Missed Case conferences (major discrepancies) have been demonstrated to be an effective educational intervention. 2 Shown to reduce the number of errors made by residents on call

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Neuroradiology and Our Radiology Residents Prior studies report a 1.7/2.6% rate of discrepancies (major/minor) on head CT examinations. 11 Neuroradiology has among the highest rate of major discrepancies (particularly CTA/MRA studies) 10 In neuroradiology, false positives can often be as harmful as false negatives Our Experience Our residency covers two busy Emergency Departments, one of which is the regional trauma center Neuroradiology studies account for the majority (~60%) of ER CT cases Our program has transitioned to 24/7 attending coverage Unforeseen failure to identify early mistakes as teaching opportunities.

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Near miss vs. True Misses at our Institution All off-hour Emergency Department Neuroradiology studies Interpreted first by residents (R2-R4) in real time Over-read by Attending faculty often within 1-4 hours (24/7) Faculty preserves the content of the preliminary report and add addenda If the patient has been discharged prior to over-read True Miss Officially documented in internal EmStat notification system We use an existing process to review formally with Residents and Attendings True Misses are becoming even more rare since the advent of 24/7 Attending coverage If the change is communicated prior to discharge or clinical intervention Near Miss Goal: New conference to review common resident near miss cases

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Residency Near Miss flight profile Inappropriate Discharge Arrive @ ER, Study performed Arrive @ ER, Study performed Resident preliminary interpretation Attending over-read Appropriate clinical management

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Approach/Methods: Collecting near miss data All resident-read on call neuroradiology studies were reviewed Senior resident (R4) weekly performed review Utilized radiology reporting system (Nuance Powerscribe) Period of 6 months (7/2014-12/2014) Identified on-call neuroradiology dictations that qualified as a resident near miss. Collected cases with educational value. Compiled in a spreadsheet for future reference.

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Methods: The Near Miss Case Conference Near miss case conference Incorporated into our existing biweekly resident run conferences Approximately 20-30 minutes dedicated to near-miss 5-10 cases to supplement conference Cases are presented by senior (R4) residents to the entire radiology residency Junior residents take cases as unknowns Senior residents act as facilitators

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Findings: Compilation of a larger volume of teaching cases. Typically collected ~5-10x the number of cases versus older true miss data Increased breadth of teaching Conference emphasized practical techniques in image interpretation. Useful search patterns Identification of pitfalls and artifacts Practical advice for similar situations Improve speed and accuracy in busy call environment Ideal complement to the classic case conference, which often focus on differential diagnosis of obvious findings and fictionalized management.

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Findings: Example Cases

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Example: Subtle Intracranial Findings Often only present on 1-2 slices Teach & discuss search patterns Ensure cortex reaches inner calvarium on all images Thin right subdural subacute/chronic hematoma Thin left chronic subdural hygroma or hematoma Two different patients

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Example: Skull base on Head CT Often focus on calvarial fractures, miss facial pathology Right lamina papyracea fracture, likely chronic Right zygomatic arch acute fracture Three different patients Perforated nasal septum

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Example: Soft Tissues on head CT Soft tissue windows are often helpful Left dislocated ocular lens Left nasopharyngeal soft tissue mass

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Example: Check your Scout images! Metallic foreign body in nasopharynx status post traumatic intubation Cervical spine C3-C4 anterolisthesis

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Example: First Cut Intracranial Findings Two different patients, both read initially as normal Which one is normal?

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Example: First Cut Intracranial Findings Neither is normal! Check to see CSF in foramen magnum on inferior-most cuts Sagittal T1W MR: Tonsillar herniation, Chiari I Sagittal T2W MR: Brainstem cyst, von Hippel Lindau

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Example: Properly aging strokes Evaluate density, mass effect, volume loss Remote right parietal infarct Recent/subacute right MCA territory infarct Prelim: Acute infarct Prelim: Age indeterminate infarct

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Example: Recognizing Artifact False positive findings reported by residents on all 3 cases below: Normal parenchyma, volume averaging, No bleed All arteries are the same density Beam hardening artifact from petrous apices Question punctate right temporal hemorrhage Hyperdense right MCA Pons/midbrain stroke

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Corollary case: TRUE hyperdense MCA Dense in relation to contralateral vessels, basilar artery and/or Vein of Galen Hyperdense left MCA Same patient CTA coronal MIP: Filling defect of left M1 segment

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Example: Satisfaction of Search When you find evidence of trauma, KEEP LOOKING! Resident reported high left frontal subarachnoid hemorrhage Missed additional blood products: subdural blood along falx Same patient

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Example: Normal variants Excellent forum for quick review: everyone can say they have seen it once Normal developmental ventricular asymmetry Choroidal fissure cystArachnoid cyst Prelim: Right lateral ventricular hydrocephalus Prelim: Right cystic lesion unknown etiology Prelim: Left subdural fluid, ?chronic

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Example: Key planes for every study Develop appropriate search pattern Missed nasal septum fracture seen only in coronal plane T10 compression fracture seen only in sagittal plane Resident identified nasal bone fractures in axial plane

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Bonus round: Guess the theme 3 different patients, preliminary read: unremarkable brain Symmetry may mask pathology! Sellar/Suprasellar MassPineal Cyst/MassHydrocephalus

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Results: Summary of trends identified and explored Subtle intracranial findings Skull base findings on Head CT Extracranial soft tissues Scout Images Foramen magnum First Cuts Aging strokes Recognizing artifact Satisfaction of search Normal variants Important planes Symmetry pitfalls and midline pathology Errors are Predictable and Preventable

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Discussion: Benefits of Near Miss Analysis Increase quantity of error data collected Aid statistical analysis Identify and predict future errors Foster an open culture of error reporting and cooperation Can be anonymous Report without threat of punitive action or patient harm Improve performance, not just measure Learn from others mistakes without having to experience it oneself Proactive Quality Improvement vs reactive Quality Assurance Save Money Increase diagnostic accuracy Avoid unnecessary procedures/tests Save Lives Increased diagnostic accuracy By definition = zero cost in patient lives or outcomes

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Discussion: Future Applications Near Miss Data collection currently can be cumbersome Automated software solutions are available for discrepancy data collection 2 Alternatively, encourage voluntary anonymous reporting on resident or attending level, as done by FAA Disseminate collected findings to residents & faculty Allow all residents to review outside of conference setting Formally incorporate into Neuroradiology rotation Practical for call preparation Quantify data Identify common institutional lapses in education Assess for improvement Ultimately, demonstrate impact on patient outcome Address changing educational needs following a transition to 24/7 attending coverage Applicable to many radiology and medical residencies across the US

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Conclusions: Near miss error collection should be incorporated into the resident neuroradiology case based education conference series Benefits include: Reducing discrepancy rates Improving patient care Increased resident knowledge Qualitative data collection New teaching opportunity Open discussion of important clinical outcomes This simple intervention can help maintain educational value in new era of 24/7 attending coverage.

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References 1.FAA Aviation Safety Information Analysis and Sharing (ASIAS). Federal Aviation Administration Web site. http://www.asias.faa.gov/ Published June 4, 2013. Accessed March 7, 2015.http://www.asias.faa.gov/ 2.Itri JN, Kang HC, Krishnan S, Nathan D, Scanlon MH. Using Focused Missed-Case Conferences to Reduce Discrepancies in Musculoskeletal Studies Interpreted by Residents On Call. AJR. 2011; 197:W696W705. 3.Lal NR, Murray UM, Eldevik OP, Desmond JS. Clinical Consequences of Misinterpretations of Neuroradiologic CT Scans by On-Call Radiology Residents. Am J Neuroradiol. 2000; 21:124129. 4.Larson DB, Nance JJ. Rethinking Peer Review: What Aviation Can Teach Radiology about Performance Improvement. Radiology. 2011; 259:626-632. 5.McKinnon, RC. Safety Management: Near Miss Identification, Recognition, and Investigation. 1 ed. Boca Raton Fl: CRC Press; 2012. 6.Program briefing. Aviation Safety Reporting System Web site. http://asrs.arc.nasa.gov/overview/summary.html. Accessed March 7, 2015. 7.Salas E, Maurino D, Curtis M. Human factors in aviation: an overview. In: Sala E, Maurino D, eds. Human factors in aviation. 2nd ed. Burlington Vt: Academic Press, 2010; 3-22. 8.U.S. National Transportation Safety Board. Aircraft accident report: Trans World Airlines, Inc, Boeing 727-231, N54328, Berryville, Virginia, December 1, 1974, Report no. NTSB-AAR-75-16. November 1975. http://libraryonline.erau.edu/online-fulltext/ntsb/aircraft-accident-reports/AAR75-16.pdf Accessed March 7, 2015. 9.Wald, Matthew L. Fatal Airplane Crashes Drop 65%. The New York Times. October 1, 2007: C1. 10.Walls J, Hunter N, Brasher PM, Ho SG. The DePICTORS Study: discrepancies in preliminary interpretation of CT scans between on-call residents and staff. Emerg Radiol. 2009; 16:303308. 11.Wysoki MG, Nassar CJ, Koenigsberg RA, Novelline RA, Faro SH, Faerber EN. Head Trauma: CT Scan Interpretation by Radiology Residents versus Staff Radiologists. Emerg Radiol. 1998; 208:125-128. Unless otherwise noted, all images licensed under Public Domain via Wikimedia Commons