Learning how to start turning the discrepancy meeting into an educational cases meeting

Transcription

1 14:30 14:50 Learning how to start turning the discrepancy meeting into an educational cases meeting Dr Jon Smith, Leeds Teaching Hospitals NHS Trust Most departments have a general or subspeciality governance meeting in which errors and discrepancies are discussed as per RCR guidelines. In 2011 in Leeds we rebranded the bi-monthly radiology meeting changing it from an errors meeting into an educational cases meeting, moving the focus from simply discussing mistakes to learning from them. In this talk we discuss the evidence behind using errors for learning, and look at how minimising fear and blame can improve teamworking and outcomes. We also provide a template for departments wishing to make that change, including organisation of the meeting, improving engagement, leading by example, effective and supportive chairing, the role of information technology (IT), and changing the culture to one of safety and trust using anonymity and positive teaching methods. Turning a discrepancy meeting into an effective educational cases meeting mirrors the cultural transition of moving away from peer review (judgement) to peer learning (teamworking and knowledge sharing). The Royal College of Radiologists. Lifelong learning and building teams using peer feedback. London: The Royal College of Radiologists, Hulson O, Smith JT. The discrepancy meeting is dead; long live the educational cases meeting. Presented at the Radiological Sociecy of North America, Chicago, Illinois, The Royal College of Radiologists. READ Newsletter 16. London: The Royal College of Radiologist, 2017.

2 14:50 15:10 Learning from experience the first 628 educational cases in Leeds Dr Andrew Koo, Leeds Teaching Hospitals NHS Trust The Royal College of Radiologists (RCR) has guidelines suggesting that all consultants should engage in and learn from discrepancy meetings, and the General Medical Council (GMC), appraisal and revalidation guidelines all support reflection and learning from errors. 1,2 Positive feedback is more effective in team building than negative feedback, and should account for more than 95% of total feedback. 3 Negative feedback may give rise to defensiveness, shame, anger, embarrassment, insecurity and disengagement. 4 We therefore tried to use our experience to develop three more positive ways of learning from errors rather than simply reviewing our failures. The first way we tried to turn the negatives into a positive was by collating the data from our educational cases meeting to identify common recurring educational themes. This allowed relevant targeted teaching both locally and nationally. Secondly the introduction of the Acknowledging and Celebrating Excellent radiology (ACE) initiative enables the usage of good spots to illustrate the same educational points as discussion of discrepancies, but with a boost in morale rather than feelings of blame or shame. Thirdly, having a database allows the production of educationally themed materials, such as posters or videos to facilitate learning. Subgroup analysis of the data can also provide information for specialties who wish to focus on one anatomical area, imaging modality or disease process. The Royal College of Radiologists. Standards for learning from discrepancies meetings. London: The Royal College of Radiologists, General Medical Council. Continuing professional development guidance for all doctors. London: General Medical Council, West MA. Effective teamwork: practical lessons from organizational research, third edition. Hoboken: Wiley Blackwell, Green P, Gino F, Staats B. Shopping for confirmation: how disconfirming feedback shapes social networks. Harvard Business School Working Paper Boston: Harvard Business School, 2017.

3 15:10 15:30 Learning from each other can effective teams and leaders result in improved patient outcomes? Dr Matthew Trewhella, North Tees and Hartlepool NHS Foundation Trust Many factors contribute to good outcomes for our patients. Some, such as report turnaround times, are easily measured while others, such as empathy and consideration are also important. Patient safety is of paramount importance, and whereas effective team working enhances safety, dysfunctional teams pose a risk. Leadership has many aspects including future planning, interfacing with other divisions, understanding peer management, collaboration with stakeholders and above, all effective communication. Radiology is a partnership between radiologists, radiographers and support staff. Only if the entire team shares an understanding and operates together effectively will outcomes be good. Many departments face great challenges around workforce, finance, equipment and estate. Whatever these challenges are, effective leadership and team working will achieve the best outcome possible. The Royal College of Radiologists and the Society and College of Radiographers. Team working in clinical imaging. London: The Royal College of Radiologists, Gunderman et al. Leadership in radiology. J Am Coll Radiol 2008; 5: Itri J. Patient-centred radiology. Radiographics 2015; 35:

4 15:30 15:50 Learning from common mistakes: missed lung cancers Dr Mike Darby, Leeds Teaching Hospitals NHS Trust Everyone, however good they are, will make occasional mistakes. Always make the effort to review old films. Use laterals if possible. Remember to check review areas in computed tomography (CT) just as much as chest X- rays. CXR

5 15:50 16:10 Learning from common mistakes: missed incidental significant findings on crosssectional imaging Dr James Stephenson, University Hospitals of Leicester NHS Trust Focus surveillance first on lesions that are curable there is no point labouring to pick up possible metastases at the expense of missing the small incidental metachronous lung, renal, breast or colon tumour. Furthermore, finding a subtle irrelevant lesion may lead to missing an important one, the so-called satisfaction of search. Avoid false-positives, not all disease is cancer, even on surveillance most patients with a significant cancer history and new symptoms will show progression, but the radiologist must always be open to an alternative non-malignant diagnosis. Care should be taken in the interpretation of incidental pulmonary nodules, as many will turn out to be benign. Falsepositives are generally unrepresented in discrepancy reviews and may be perceived as less important; however, they do consume resources and lead to unnecessary investigation, intervention and worry. Failing to spot complications of cancer for patients with advanced cancer on treatment, failing to detect a small site of new disease is unlikely to have a strong deleterious effect to the patient, unless there is a clear alternative treatment; however, the radiologist does have one very important task in these patients: the palliative sweep. Advanced cancer patients have a high chance of developing complications that can be successfully ameliorated, improving their quality of life. Many of these problems, such as bowel or bile duct obstruction may be apparent clinically, but the radiologist ideally will detect these problems early to instigate palliative treatment. New symptoms and signs may not be communicated to the radiologist a key problem in identifying complications of cancer is when surveillance scans are booked weeks or months in advance. This is a useful process to plan computed tomography (CT) examination appointments for patients on cancer pathways or clinical research trials, but it has the disadvantage that new symptoms may not be communicated to the radiologist. It is useful to have a system where the scanning radiographers can alert the radiologists to any additional complaints the patient may mention at their appointment. Pick up the phone make sure all significant unexpected findings are adequately communicated. An electronic reporting system is no longer good enough in modern busy hospitals. The single biggest problem in communication is the illusion it has taken place. Ivan CV, Mullineux JH, Shah V et al. Peripheral vision: abdominal pathology missed outside the centre of gaze. BR J Radiol 2018 June 27 : doi: /bjr [Epub ahead of print]

6 Morgan B, Stephenson JA, Griffin Y. Minimising the impact of errors in the interpretation of CT images for surveillance and evaluation of therapy in cancer. Clin Radiol 2016; 71(11): Brady A, Laoide RO, McCarthy P. Discrepancy and error in radiology: concepts, causes and consequences. Ulster Med J 2012; 81: 3 9.

7 16:10 16:30 Learning from common mistakes: missed fractures Dr Dominic Barron, Leeds Teaching Hospitals NHS Trust A good history and examination still remains key to any case. Communication. Do not assume that clinicans understand the limitations of radiology. Be prepared to educate your clinical colleagues. Dismiss the patient at your peril no scan/study shows pain. Harrison W, Newton AW, Cheung GC. The litigation cost of negligent scaphoid fracture management. Eur J Emerg Med 2015; 22(2): The Royal College of Radiologists. Clinical radiology UK workforce census 2016 report. London: The Royal College of Radiologists, (last accessed 7/8/18