Radiological Errors- What? Why? How? When?Audit Aims •Provide a robust, sustainable and useful...

Radiological Errors-

What? Why? How? When?

Pamela Parker

Lead Sonographer

The greatest of

faults, I should

say, is to be

conscious of

none

Thomas Carlyle philosopher,

satirical writer, essayist, historian

and teacher.

Born: 4 December 1795,

Died: 5 February 1881

Clinical Govenance

"Clinical governance is a system through

which NHS organisations are accountable

for continuously improving the quality of

their services and safeguarding high

standards of care by creating an

environment in which excellence in clinical

care will flourish."

(Scally and Donaldson 1998, p.61)

Main Components of Clinical

Governance

• Identifying what can and does go wrong

during care

• Understanding the factors that influence

this

• Learning lessons from any adverse events

• Ensuring action is taken to prevent

recurrence

• Putting systems in place to reduce risks

Main Components of Clinical

Governance • Clinical audit

• Education, training and continuing

professional development

• Evidence-based care and effectiveness

• Patient and carer experience and

involvement

• Staffing and staff management

Patient and carer experience and

involvement

• Complaint, incident and compliment

analysis

• Patient satisfaction surveys

– Staff

– Service

• Patient Information Leaflet Review

And why do you

look at the

speck in your

brother's eye,

but do not

consider the

plank in your

own eye?

Matthew 7:3

Incident Review

What’s gone wrong?

Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13

DATIX

NT Data 2 4 4 1 1 2

Reports 2 2

Patient Incidents

(Falls etc) 1 1

Staff Incidents (Falls

etc) 1

Referral Issues 1

Needle Stick 1

Understanding the influencing

factors

Patient Complaints

What’s gone wrong? PALS Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13

Rushed scan. (Obs) 1 2

Sonog attitude (Obs) 2 2 1 1

Waiting list (MSK) 1 1

Sonog attitude (MSK) 1 2

Sonog attitude (A&E) 1

Pt perception MSK

Pt perception TRUS

Sonog attitude (Gen) 1

PALS Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15

Rushed scan, poor

communication 1

Unhappy with Souvenir

Scans 2 1

Sonographer attitude 1

Pt wanted cons scan 1

Pt scanned as IP an

OP not required. Pt

states was not

informed 1

Post surgical FB

reported - surgeon

disagrees 1

Staff focus

• Patient Satisfaction surveys

– How good was your sonographer today at

each of the following?

Listening to you

Explaining the

procedure

Explaining how to

get your results

Explaining when to

get your results

Being Polite

Making you feel at

ease

What’s gone right?

What’s gone right?

Very professional, felt really relaxed

The sonographer is great, She put me at ease

Please add any other comment you want to make about this sonographer.

Brilliant, helpful and happy people

Procedure quick, polite and efficient

Sonographer was very polite, thank you

Very polite and easy to understand.

Made me feel so at ease. Relaxing voice and was very efficient and professional.

Very relaxed experience

The sonographer was exceptionally clean and tidy and very polite. She explained

everything that was going on.

top marks 10/10

I initially felt shy but put at ease with such caring staff

I liked her she was nice, thank you lovely lady

there were 3 people in the room everyone was very kind and polite

don't want to lose that

The Sonographer deserves pay rise because she knows her job well and society

Staff focus and multi-disciplinary

working

• Sonographer Multisource Feedback

– The purpose of this survey is to provide

sonographers with information about their

work through the eyes of those they work with

– It is intended to help inform their further

development

Sonographer Multisource Feedback

Happiness Scores!

Clinical Audit

• Quality Assurance vs Clinical Audit

• Clinical Examination vs Technical Issues

• Staff quality Vs Equipment Quality

Background

• Sonographers now undertake and report

medical ultrasound examinations in most

UK hospitals

• RCR view this as a delegated task

• Quality assurance is important

– to ensure that delegation is appropriate

– to guarantee safe and effective practices to

service users

Implementing Audit

• Ultrasound is renowned for its operator

dependence

• A ‘real-time’ imaging modality

• Immediate interpretation of the moving

ultrasound image

• An audit programme should be a process

of review, learning and improvement for

both the service and individuals

Audit Aims

• Provide a robust, sustainable and useful

audit and case review process that

identifies needs for service improvement

that will ultimately lead to better patient

care.

• Provide a process of review and learning

that contributes positively to sonographers’

continuing professional development.

Clinical Audit

• A robust, sustainable audit programme for

diagnostic ultrasound is hard to implement

• Time and resources are required

• Relevant to clinical practice

• No one accepted method of performing a

review of practice

– BMUS Recommended Audit Tool

British Medical Ultrasound Society

• The BMUS recommended peer review

audit tool

• Reproducible mechanism with which

quality factors can be measured reliably

and repeatedly.

– Image Quality

– Report Quality

– Clinical Quality

Recommendations for Use

• Audit is undertaken in conjunction with a

discrepancy meeting.

• A tolerance level of acceptable quality is

agreed

• Cases falling below this tolerance level

should be discussed openly within a

discrepancy meeting

• Learning points and further action agreed

Points to Consider

• Randomised audit sample

• Anonymity

• Reviewers

• Quality Benchmarks

• Feedback

• Learning from discrepancies

Score Criteria

IMAGE QUALITY (I)

3 Good Image Quality

2 Acceptable Diagnostic Quality

1 Poor Image Quality

REPORT QUALITY (R)

3 Report Content and Structure

Optimal

2 Report of Acceptable Quality

1 Poor Report Quality

CLINICAL QUALITY (C)

Yes = 1 point, No = 0 points

Clinical Referral Appropriate

Clinical Question Answered

Appropriate advice or conclusion

Clinical Audit – Is anything

wrong?

Discrepancy Reflection

Type of Discrepancy

A Observation

B Interpretation

C Poor imaging technique

D Poor Wording

Grade of discrepancy

0 No Discrepancy

1 Discrepancy with report –

no action required

2 Discrepancy with report –

report amended

3 Significant discrepancy with

report – action required

What’s gone wrong?

Education, Training and CPD

• Literature reviewed and presented at CPD

meeting : Guidelines updated

• GB imaging presentation given to support

practice

• Discussed with sonographer. Need to be

mindful of terminology used in reports

• Equipment issues identified resulted in

equipment being transferred from main

service

Summary – So Far

• Identifying what can and does go wrong

during care

• Understanding the factors that influence

this

• Learning lessons from any adverse events

• Ensuring action is taken to prevent

recurrence

• Putting systems in place to reduce risks

Learning lessons from any

adverse events • Discrepancy Meetings

• PDR’s

– Team objectives

– Team results

• Operational Group Meetings

• Staff meetings

• Incident reporting

• Incident recording

Gallstones – US features

Gallstones?

Gallstones?

Gallstones ?

YES √ No x – Gas filled duodenum

Duty of Candour

Background

• 27th November 2014 marked an historic

moment for NHS in England

• Statutory duty of candour comes into force

following two decades of campaign

• Regulation 20: Duty of Candour. Care

Quality Commission

• March 2015

Definition

• A legal duty to be open and honest with

patients or their families when things go

wrong that can cause harm

• Duty of Candour aims to help patients

receive accurate, truthful information from

health providers

Definition

• ‘Any patient harmed by the provision of a

healthcare service is informed of the fact

and an appropriate remedy offered,

regardless of whether a complaint has

been made or a question asked about it’

www.professionalstandards.org.uk

Why?

• 24% The percentage of NHS trusts that

regularly inform patients of safety

incidents.

• 1 Million : The estimated number of patient

safety incidents in English hospitals every

year

• 50% The percentage of patient safety

incidents that are avoidable

Why?

• £9 -10 billion :The potential liability of the

NHS; (based on reporting from NHS trusts

about medical accidents, deemed to be

negligence risks).

Development

• “Robbie’s Law”

Robbie’s Law

• In December 1989, Robbie Powell aged

10, of Ystradgynlais in Wales is

hospitalised for four days.

• He loses 25% of his body weight and is

critically dehydrated.

• The hospital suspects Addison’s disease

• Doctors there order an ACTH test for the

condition, but this isn’t followed through.

Robbie’s Law

• The test recommendation isn’t

communicated to the Powells, but is

communicated to his GPs. Instead the

Powells are told by the hospital that

Robbie suffers from gastroenteritis caused

by a throat infection

Robbie’s Law

• Four months later, in April 1990, Robbie

again suffers from vomiting, weight loss

and acute stomach pains.

• He is seen seven times by five doctors

over 15 days.

• None of them perform the basics: check

symptoms, do a blood test or refer to the

hospital.

Robbie’s Law

• Only one doctor checks the medical

records, containing the crucial warning

from the hospital.

• He dies from critical dehydration as a

result of Addison’s disease.

Robbie’s Law

• His death could have

been avoided, but

due to a combination

of mismanagement,

dishonesty and

deliberate cover-up,

none of the doctors

are prosecuted

http://www.robbieslawtrust.co.uk/summary/

Outcome

• Robbie’s Law and the Duty of Candour is

born from a seriously dire need for

openness and honesty in healthcare.

• Robbie’s Law means that healthcare staff

must tell patients and their next of kin the

truth, when a patient safety incident occurs

Openness

• Letter sent to the patient with apologies

given about what had happened.

• The patient came to see the treating GP

shortly after receiving the letter.

• He had been giving thought to speaking to

a solicitor about the delay in diagnosis

• On reflection he had been struck by the

openness, the apologies and the care and

support of the GP

Learning

• The patient felt that the most important

thing to happen was for the doctors to

learn from the incident

Being Open When Errors Are

Made • Open discussions between the patient and

the healthcare provider when things go

wrong.

• Acceptance by healthcare staff that open

conversations will take place at an early

stage.

• Reduction in overly defensive approaches

to information sharing about incidents in

relation to the patient in question.

Triggers

• The death of a patient when due to

treatment received or not received (not

just their underlying condition).

• Severe harm - in essence permanent

serious injury as a result of care provided.

• Moderate harm - in essence non

permanent serious injury or prolonged

psychological harm.

Moderate harm - US

• Misdiagnosis leading to unnecessary

surgery

• Misdiagnosis leading to delays in

treatment

• Therapeutic treatment delivered incorrectly

How do we deal with this?

Duty of Candour

Radiology Report Discrepancy Flowchart

Radiology Report Discrepancy Flowchart

Radiology review meeting held & discrepancy

identified

Level of radiological discrepancy determined at

review

Grade 0 or Grade 1

Grade 2 and 3 (no clinical

significance)

Grade 2 and 3 with reasonable likelihood of clinical significance

Decision by referrer/clinician following discussions between Radiology and the clinical team. Should the patent be informed?

Moderate (2) Major (3)

Date apology provided recorded on DATIX by member of staff who gave the apology

Written apology offered to the patient/family

Actions taken to provide patient with explanation and apology recorded on DATIX by service or specialty lead

Letter sent to [email protected] for

inclusion on DATIX

10 days

Moderate (2) Major (3)

Serious Incident / Never Event investigation

Yes or No

Error recorded in discrepancy meeting

notes DATIX closed if Grade

2 or 3

Investigation concluded

Summary of discrepancy meeting notes discussed at RMT on a quarterly basis and included in Imaging

DIG report

Letter including outcomes and learning

approved by Health Group triumvirate prior

to sending to the patient/family

Letter offering to share final report and an offer to meet with the panel to discuss

the report sent to patient/family

Letter sent to [email protected] for inclusion on DATIX

10 days

The incident investigation must be shared with the patient/family. This includes action plans, details of investigations and means actual written

reports and if necessary, plain English explanations of their contents.

Radiology Lead for the discrepancy meeting discusses with referring clinical team and informs referrer via letter of error and any remedial actions

taken (such as arranged further scans)

Written apology is provided to the patient/family

Radiology records incident on DATIX

Ultrasound to discuss discrepancy with

Radiologist before notifying referrer.

No

Yes

Not significant Significant

Duty of Candour - In Practice

• Errors discussed and graded at

discrepancy meeting

• Where deemed to be a moderate

disagreement in the report an apology is

given via the referring clinician

• Actions recorded

How do we deal with this?

We acknowledge our mistakes and say sorry

What is an apology?

• Clinical staff may

worry that being open

with patients may

compromise the

ability to deal with a

claim if one is

subsequently made

by the patient

• In reality candour is

all about sharing

accurate information

with patients

• The facts are the

facts and staff should

be supported to help

patients understand

what has happened to

them.

What is an apology?

• Where staff should be

more cautious is

where the facts are

not yet know or where

they are being asked

to speculate beyond

what is known.

• It can be more

damaging to a

relationship with the

patient to speculate

inaccurately than to

investigate and find

the facts and then

provide the extra

information.

Apology or Admission of Liability

• Saying sorry is not an admission of

liability; it is the right thing to do

• NHS LA does not withhold cover if an

apology or explanation has been given

www.nhsla.com

http://www.nhsla.com/

Clinical Governance - Summary

• What? – Clinical

– Staff

– Patient Focus

• Why? – Basis for quality care

• How? – Audit

– Surveys

• When? – Continuously

Radiological Errors- What? Why? How? When?Audit Aims •Provide a robust, sustainable and useful...

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