Radiology errors and negligence

6 FEBRUARY 2015

RADIOLOGY ERRORS AND NEGLIGENCE Venue: British Dental Association, London CPD: 5 CREDITS

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BIR ANNUAL CONGRESS 2015 4–5 NOVEMBER LONDON • Room 1

Primers for the non-specialists

Day 1

Session organised by Dr David Wilson, Consultant Interventional MSK radiologist, Oxford University Hospitals NHS Trust

Day 2 Clinical hybrid imaging in oncology • Room 1

Session organised by Dr Gopinath Gnanasegaran, Consultant Physician in Nuclear Medicine, St Thomas’ Hospital

• Room 2

• Room 2

Session organised by Mr Andy Rogers, Head of Radiation Physics, Nottingham University Hospitals NHS Trust

Session organised by Dr Hardi Madani, Radiology Registrar, Royal free London Hospital

Radiation protection

More information available soon at www.bir.org.uk

Emergency radiology Essentials for the radiology trainee Session organised by Dr Hardi Madani, Radiology Registrar, Royal Free London Hospital, and Dr Ausami Abbas, Cardiothoracic Radiology Post CCT Fellow, University Hospital Alberta

Welcome and thank you for coming to ‘Radiology errors and negligence’ organised by The British Institute of Radiology.

We wish you a very enjoyable and educational experience.

Certificate of attendance This meeting has been awarded 5 RCR category I CPD credits.

Your certificate of attendance will be emailed to you within the next two weeks once you have completed the online event survey at: https://www.surveymonkey.com/s/radiologyerrorsandnegligence

BIR Annual Congress 2015: 4–5 November, London

We are most grateful to

for supporting this conference.

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Programme

09:00 Registration and refreshments 09:25 Welcome and introduction

Dr Teik Choon See, Consultant Radiologist, Addenbrooke’s Hospital 09:35 Errors in radiology

Dr Teik Choon See, Consultant Radiologist, Addenbrooke’s Hospital 10:05 Discrepancy meetings: moving forwards

Dr Mary Roddie, Consultant Radiologist,

Imperial College Healthcare NHS Trust 10:35 Maintaining high professional standards framework

Mr Stuart Craig, Partner for Mills & Reeve LLP 11:05 Refreshments 11:30 Integrating human factor in radiology

Professor Bryn Baxendale, Consultant Anaesthetist, University of Nottingham 12:00 Thoracic imaging

Dr Nick Screaton, Consultant Cardiothoracic Radiologist, Papworth Hospital 12:30 Lunch 13:30 Abdominal trauma imaging

Dr Sara Upponi, Consultant Radiologist, Addenbrooke’s Hospital 14:00 MSK imaging

Dr Andoni Toms, Consultant Radiologist,

Norfolk and Norwich University Hospitals 14:30 Breast imaging

Dr Matthew Wallis, Consultant Radiologist, Addenbrooke’s Hospital 15:00 Refreshments 15:30 Paediatric imaging

Dr Caren Landes, Consultant Paediatric Radiologist and

Radiology Clinical Lead, Alder Hey Children’s NHS Foundation Trust 16:00 Head and neck imaging

Dr Elizabeth Loney, Consultant Radiologist, Bradford Teaching Hospitals 16:30 Quality assurance in radiology reporting: peer feedback

Dr Richard FitzGerald, Vice-President, Faculty of Clinical Radiology,

The Royal College of Radiologists 17:00 Close of event 2

Certificate of attendance This meeting has been awarded 5 RCR category I CPD credits.

Your certificate of attendance will be emailed to you within the next two weeks once you have completed the online event survey at: https://www.surveymonkey.com/s/radiologyerrorsandnegligence BIR Annual Congress 2015: 4–5 November, London

Join the BIR today and receive 20% off your membership fee As a thank you for attending today’s event we would like to offer you this great deal Be part of the only multi-disciplinary membership organisation for everyone interested in medical imaging

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Speaker profiles Professor Bryn Baxendale Consultant Anaesthetist, University of Nottingham Bryn was appointed as a Consultant Anaesthetist at Nottingham University Hospitals in 1998 and currently has clinical responsibilities related primarily to vascular and emergency surgical services at QMC campus. In 2009 he was appointed as an Honorary Professor by the School of Psychology at the University of Nottingham.

He has been President of the Association of Simulated Practice in Healthcare (2009–2014), which is the national learned body in relation to the use of simulation and related innovative learning technologies for professional education and training, workforce development, and quality and patient safety improvement. In 2012 Bryn joined the Health Education England (HEE) Strategy Board for Technology Enhanced Learning, and is also a member of the HEE Human Factors Expert Working Group.

His interests relate to leading the widespread adoption of simulation-based methodologies across the healthcare system in order to enhance patient safety and quality of care. Specifically this involves exploration of how best to enhance the development of expertise in individual professionals and multiprofessional teams, and how to support organisational learning and attainment of high reliability amidst complexity and constrained resources.

Mr Stuart Craig Partner for Mills & Reeve LLP Stuart is a Partner with national law firm Mills & Reeve LLP specialising in employment law. He frequently advises on matters where specialist knowledge of the NHS is required, in particular in relation to disciplinary and performance issues involving medical practitioners. Stuart’s expertise has been acknowledged by the leading independent legal directories, in which he is described as “highly recommended in the healthcare sector” and as an “outstanding lawyer appreciated for his wise solutions.”

Dr Richard FitzGerald Vice-President, Faculty of Clinical Radiology, The Royal College of Radiologists • • • • •

Consultant Radiologist, Royal Wolverhampton Hospitals NHS Trust 1986-March 2014, part-time May 2014 onwards Chairman, West Midlands Association of Radiologists 1997-1999 Elected Member of Royal College of Radiologists (RCR) Radiology Faculty Board 1999-2002 Member of the RCR Standards Subcommittee 2003-2009 and RCR European Subcommittee 2001-2009 Elected Member of RCR Council 2010-2013 4

• • • •

Elected Member of Radiology Professional Support and Standards Board 20112014 General Medical Council Radiologist Assessor 2002-2013 Member of various local and national BMA Committees 1994-2010 Publications and lectures on Improving Radiologist Working Lives, Fair Medical Regulation, Radiological Error and Teleradiology

Dr Caren Landes Consultant Paediatric Radiologist and Radiology Clinical Lead, Alder Hey Children’s NHS Foundation Trust Caren is a Consultant Paediatric Radiologist and Service Group Lead at Alder Hey Children’s NHS Foundation Trust.

Her expertise within paediatric radiology covers the full range of paediatric imaging including plain X-ray, ultrasound, fluoroscopy, cross sectional imaging (CT and MRI) and nuclear medicine, but she has a special interest in musculoskeletal radiology and imaging in suspected non-accidental injury.

Dr Landes has lead the Departmental Discrepancy Meeting for 3 years until 2012 and as a result of her expertise she receives regional and national referrals for review of musculoskeletal imaging from radiological and clinical colleagues with an emphasis on imaging in cases of suspected non-accidental injury. As a result of this she has experience of discrepancies seen in paediatric imaging in both the tertiary setting and in the referring hospitals.

Dr Elizabeth Loney Consultant Radiologist, Bradford Teaching Hospitals Elizabeth is a Consultant Head and Neck Radiologist at Bradford Teaching Hospitals NHS Foundation Trust where she has worked for the last 8 years. Prior to this she was a Consultant Radiologist at Queens Hospital, Burton on Trent, for 3 years and did her Radiology Training at The Royal Free and St Marys’ Hospitals, London.

She originally studied to be an ear, nose and throat (ENT) Surgeon but after ‘seeing the light-box’ decided to combine her interest in Head and Neck with Anatomy in a Radiological career. She is currently the Vice-Chair and Chairman Elect of the British Society of Head and Neck Imaging and obtained the European Diploma of Head and Neck Radiology in 2013, becoming a Fellow of ESHNR. Elizabeth lectures nationally and internationally on all things ‘Head and Neck’. Her practice covers all modalities except nuclear medicine, and all areas from the clavicle upwards including imaging for cochlear, middle ear and TMJ implantation. As the only UK member of the Scientific Subcommittee for The European Congress of Radiology (ECR) 2015 and 2016 she has been involved in vetting and scoring over 150 abstracts and is also lecturing at ECR in March 2015. She is a past Part 1 FRCR Anatomy Examiner, being one of the founding members of the Anatomy Working 5

Group. She also examines Anatomy for the Royal College of Surgeons of England both in the UK and abroad.

Elizabeth reviews for 8 Journals including Clinical Radiology, European Radiology and the British Journal of Oral and Maxillofacial Surgery. She convenes an annual course in Anatomy for FRCR part 1 in Leeds and is Special Interest Lead for the Leeds– Bradford Radiology Academy in Head and Neck. She is an extremely enthusiastic teacher and keen to disseminate her knowledge of Head and Neck Imaging to all who are interested.

Dr Mary Roddie, Consultant Radiologist, Imperial College Healthcare NHS Trust Mary is a Thoracic Radiologist at Imperial College Healthcare NHS Trust and Honorary secretary of the British Society of Thoracic Radiology. Her interests include thoracic ultrasound and the development of digital teaching collections of images and she runs courses on both of these subjects as well as being a founder member of the UK OsiriX user group. She has been involved in the discrepancy meeting programme at Imperial College Healthcare NHS Trust since its inception and has more recently developed an innovative virtual discrepancy meeting format that has demonstrated increased radiologist involvement in and engagement with the process.

Dr Nick Screaton Consultant Cardiothoracic Radiologist, Papworth Hospital Nick is a Consultant Cardiothoracic Radiologist at Papworth Hospital, Cambridge.

His special interests include pulmonary hypertension, interstitial and airways diseases, and lung cancer screening. He was Radiology Clinical Director in Papworth Hospital 2004–12 and President of the British Society of Thoracic Imaging 2009–13. He sits on the British Thoracic Society Bronchiectasis Guidelines development group, National Institute of Clinical Excellence Idiopathic Pulmonary Fibrosis Quality Standards Committee, National Institute of Clinical Excellence Guidelines Updates Standing Committee, and National Clinical Commissioning group for Specialised imaging (stakeholder representative).

Dr Teik Choon See Consultant Radiologist, Addenbrooke’s Hospital Teik Choon is a Consultant Interventional Radiologist at Addenbrooke’s Hospital, Cambridge. His special interests include hepato-biliary interventions and interventional oncology. He is actively involved in clinical governance, management of radiology errors and quality improvement locally and nationally. He chaired the BIR East of England branch since its inception in 2010 to 2013. He initiated a number of local, regional and national educational events related to interventional radiology, patient safety, radiology errors and the Cambridge FRCR course.

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Dr Andoni Toms Consultant Radiologist, Norfolk and Norwich University Hospitals Andoni is a Musculoskeletal Radiologist at the Norfolk and Norwich University Hospital and an Honorary Professor at the University of East Anglia. He graduated from Medical School in London in 1991, completed his Radiology training in Cambridge in 2001 and a Musculoskeletal Radiology Fellowship at the University of Toronto in 2002. He was appointed a Consultant Radiologist at Norfolk and Norwich University Hospitals NHS Foundation Trust in 2002. His particular areas of imaging research interest include the imaging of orthopaedic prostheses—the basis for his PhD awarded in 2011—and osteoarthritis. He has published over 90 peer reviewed papers and given over 40 invited lectures at national and international scientific conferences.

Dr Sara Upponi Consultant Radiologist, Addenbrooke’s Hospital Sara is a Consultant Radiologist at Addenbrookes Hospital Cambridge with interests in abdominal and trauma imaging. She is clinical lead for trauma imaging and has been co-lead for the local discrepancy meeting for the last 6 years.

Dr Matthew Wallis Consultant Radiologist, Addenbrooke’s Hospital • • • • • •

•

•

Consultant Radiologist, Cambridge Breast Unit since November 2007 Associate Lecturer, University of Cambridge Director of Screening since July 2010 – September 2014 Before that Director, Warwickshire, Solihull and Coventry Breast Screening Programme for 19 years Past President, European Society of Breast Imaging 2010–2013 Clinical imaging lead (Breast) at the Cambridge Biomedical Research Centre and the Experimental Cancer Medicine Unit: - Monitoring and predicting breast tumour response in phase 1 and 2 trials - Optimising existing and evaluating new imaging techniques for the breast and axilla His other research interest is anything and every thing affecting radiological and surgical performance in breast screening and using data to improve performance.

In particular related to non operative diagnosis, staging of the breast and the diagnosis and management of ductal carcinoma in situ 86 peer review papers

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Abstracts Errors in radiology Dr T C See Learning objectives: • Radiology errors are multifactorial. A systematic approach is required to minimise errors • The most common cause of medical malpractice suits against radiologists is error in diagnosis, followed by procedural complications and inadequate communication • The largest number of claims concerned missed or delayed diagnoses of cancer • Adhere to standard of care and minimise risks: Practice and Quality Improvement Guidelines, Patient Safety Checklist, Training and Updates, Improve Communication Skills, Liability Insurance Discrepancy meetings: moving forwards Dr Mary Roddie Departmental discrepancy meetings facilitate collective learning from radiology discrepancies and errors and thus improve patient safety. Royal College of Radiologists standards state that all radiologists should participate regularly in radiology discrepancy meetings with a minimum attendance of at least 50% of meetings. With increasing pressure on radiologists’s time and in large Trusts spread across different hospitals it may be difficult for radiologists to attend and participate in discrepancy meetings. This presentation will describe an innovative virtual discrepancy meeting format that has made a significant improvement in radiologist attendance and engagement with the shared learning process of discrepancy analysis. It has also greatly increased the number of cases being submitted for inclusion and analysis.

Maintaining high professional standards framework Mr Stuart Craig “Maintaining High Professional Standards In The Modern NHS” (“MHPS”) is the framework setting out how concerns that arise in respect of medical practitioners employed in the NHS should be handled. In the decade since it was introduced it has given rise to many issues and legal disputes. In this session, Stuart Craig, a Partner with national law firm Mills & Reeve LLP, will summarise the issues that have arisen and examine the lessons to be learnt from a recent leading High Court decision in which Stuart was involved.

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Integrating human factor in radiology Professor Bryn Baxendale This presentation will describe the relevance of Human Factor (HF) science to professional practice in healthcare, with emphasis on how human fallibility and limitations in performance are ever present in our daily lives at work and at home. Strategies to improve awareness amongst staff and build HF capability and organisational resilience within local teams and services will be outlined.

Thoracic imaging Dr Nick Screaton As with other organ systems, error in chest imaging may range from perceptual error (over or undercalling), interpretive error, communication failure or lack of clarity with recommendations. Various cognitive and system factors contribute to error and an understanding of these and how to safeguard against them can improve quality and reduce error. While improvement in IT undoubtedly provide opportunity to reduce error also introduce others such as voice recognition error.

Chest imaging is far from immune to error. Data from the 1940s showed discrepancy in 10–20% of CXR reading in patients with suspected TB. 19% of lung cancers presenting as a nodule (median 1.6cm) on CXR are missed prospectively with reported rates of between 25 and 90% being described.

Interpretation of the projectional CXR is complicated by superimposition of structures but though cross sectional imaging such as CT overcomes this errors of detection remain common. This includes detection of lung nodules, pulmonary emboli and monkeys. But detection is only one part of the job, others include interpretation and communication. In each element both automatic and systematic processes come into play.

Learning objectives: • Describe common examples of error/discrepancy in chest imaging and their prevalence • Identify what factors may contribute to them • Discuss how these may in part be mitigated Abdominal trauma imaging Dr Sara Upponi Imaging in trauma is challenging owing to both the potential complexity of injury and necessity for a timely report. Discrepancies related to CT in abdominal trauma will be presented. These commonly include injuries that may be clinically occult often related to the bowel and retroperitoneum. Report construction and communication within the wider trauma team will be discussed.

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MSK imaging Dr Andoni Toms The most common cause for medical malpractice suits against radiologists in the USA is a failure to diagnose in the musculoskeletal system. A large proportion of these are perceptual errors involving missed fractures or metastases. Scaphoid fractures are one of the most commonly missed fractures but the failure to diagnose is arguably a system failure rather than a purely radiological failure.

Failure of interpretation accounts for about one fifth of errors. In the musculoskeletal system these often involve over-calling benign disease as malignant. Age-related fibrofatty changes, and haematopoesis, in spinal bone marrow can trigger a diagnosis of marrow infiltration. Inflammatory spondyloarthropathies can be mistaken for spinal metastases. Focal vertebral abnormalities such as aggressive haemangiomas, and Chronic Recurrent Multifocal Osteomyelitis or SAPHO syndrome, can present as focal malignancies.

Hyperintense T2 Weighted signal changes in intervertebral discs are not always associated with infection and calcific tendinopathies of the spine can mimic an infective discitis. These are undoubtedly underdiagnosed but easy to identify with CT. Heterotopic ossification of soft tissue (formerly known as myositis ossificans) is associated with marked inflammatory changes early in its evolution that are sometimes interpreted as aggressive soft tissue sarcomas, but characteristic features allow an early diagnosis. Similarly acute calcific enthesopathies can present with apparent cortical destruction and aggressive periosteal changes that are often interpreted as cortical metastases or osteogenic tumours.

Breast imaging Dr Matthew Wallis Breast imaging/services are perceived to be a major source of medico-legal complaints and are said to put trainees off. In reality errors are stressful but as an individual and a service are infrequent. Errors in screening and symptomatic practices can be classified in the same way as the rest of radiology: perception, interpretation and process and I will show examples.

The problem with screening is that we invite well women and despite all the publicity there is still a perception of ‘perfection’. We also have large volumes of monitoring data so when things go less than perfectly ‘is this a bad radiologist?’ and ‘we must stop this happening again’ frequently surface. I will discuss the difficulties of addressing these sorts of questions with data that is primarily service based and is usually used to help improve performance.

Finally I will offer some personal thoughts on what in the 1990s screening called ‘disclosure of audit’ but is now called duty of candour. There is good evidence that if we ‘break bad news’ badly then there are long-term consequences, the same is true of candour. Forcing information, on someone trying to come to terms with a diagnosis of cancer, breaks all the principles of good communication.

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Paediatric imaging Dr Caren Landes Errors and discrepancies in paediatric radiology are often related to inexperience and lack of knowledge of the normal developmental anatomy.

This presentation will aim to raise awareness of the more common pitfalls encountered when interpreting paediatric imaging and will give advice as how to avoid them.

Head and neck imaging Dr Elizabeth Loney Errors are deviations from the norm, whether they result in harm or not. One could think of them as falling into one of 3 groups: • • •

Mis-s: you didn’t see anything Mis-interpretation: you saw something but interpreted it incorrectly Mis-take: you saw something and interpreted it, but failed to appreciate its full extent or do further appropriate investigations

Educational aims: • This lecture will use real error cases collected over a number of years that demonstrate common pitfalls in Head and Neck Radiology • For each case the audience will have questions posed and relevant images demonstrated. Participants will be able to test themselves as to whether they would have spotted the pathology in question • Lessons to be learnt will be given after each case Review areas will be highlighted along with common errors made when staging head and neck cancers. I hope that attendees will feel that the ‘interactive’ nature of the session provides an opportunity for reflective learning.

Learning objectives: • to be familiar with common errors in head and neck radiology.

• to develop a systematic reporting approach including review areas in the same way as when reporting chest radiographs Quality assurance in radiology reporting: peer feedback Dr Richard FitzGerald http://www.rcr.ac.uk/docs/radiology/pdf/BFCR(14)10_Peer_feedback.pdf Following the publication of the the 1781 page report of the 2nd Francis Inquiry into the Mid Staffordshire Foundation Trust, containing 290 recommendations, the Health Secretary asked Don Berwick to lead an expert group to produce a 11

report on next steps toward a better and safer NHS. The resultant 46 page report, A Promise to Learn, a Commitment to Act: Improving the Safety of Patients in England–the Berwick Report, had 3 key points: • The importance of safe staffing levels • The need for life long learning by all healthcare professionals • “Fear is toxic to both safety and improvement” The excellent Royal College of Radiologists Radiology Events and Discrepancies (RCR READ) publications are very much in the spirit of Berwick recommendations of reducing fear in the workplace and life long learning. Prompted by very low electronic hit rates, they will in future be published in paper as well as electronically. Please consider submitting cases to read@rcr.ac.uk.

Berwick recommendations have been the major influencing principles behind the recent RCR publication Quality Assurance in Radiology Reporting: Peer Feedback which encourages daily learning through IT facilitated, workflow efficient, supportive text feedback delivered to primary reporters.

While some of this would arise through multi-disciplinary team participation, and Learning from Discrepancies Meetings, there is even greater potential for this in routine practice when reviewing prior imaging and reports. Most times this feedback should be quick and brief e.g. “good spot”, “see follow up CT/MR etc”, “pathology showed x”, “see improvement on y”. In a small minority of cases, it would be “when is a good time to discuss x?”.

Supportive text feedback is what it says. It is not double reporting, supplementary reporting, scoring or classification. It can be a major contributor to efficient life long learning for all Radiologists. Review alone is not feedback.

Culture change as well as better IT is required. The Berwick Report states, “In the end, culture will trump rules, standards and control strategies every single time, and achieving a vastly safer NHS will depend far more on major cultural change than on a new regulatory regime”.

Any cyberbullying should be dealt with using an organisation’s Bullying and Harassment Policies. It is envisaged that electronic text peer feedback will, in time, become as routine for Radiologists as review of relevant prior imaging. The RCR will audit this during 2016.

Key References: A promise to learn–a commitment to act. Improving the safety of patients in England. National Advisory Group on the Safety of Patients in England. August 2013.

Rethinking peer review: what aviation can teach radiology about performance improvement . DB Larson, JJ Nance. Radiology 2011: 259: 626–632 12

Knowledge sharing in radiology. R Gunderman, S Chan. Radiology 2003: 229: 314–317 Inter-rater variation in scoring radiological discrepancies. B Mucci, H Murray, A Downie, K Osborne. The British Journal of Radiology 2013. doi.10.1259/ bjr20130245 Inter-rater agreement in the evaluation of discrepant imaging findings with the RADPEER system. LC Bender et al. Am J Roentgenol 2012: 199: 1320–1327 Peer review comments augment diagnostic error characterisation and departmental quality assurance: 1 year experience from a childrens hospital. RS Iyer et al. Am J Roentgenol 2013: 200: 132–137 Commentary on discrepancies in discrepancy meetings. P McCoubrie, R FitzGerald. Clinical Radiology 2014: 69: 11–12

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FORTHCOMING EVENTS EMERGENCY INTERVENTIONAL RADIOLOGY 13 FEBRUARY 2015 LONDON 4TH ANNUAL SPECT/CT SYMPOSIUM: CURRENT STATUS AND FUTURE DIRECTIONS OF SPECT/CT IMAGING 23 FEBRUARY 2015 LONDON THE TECHNOLOGY AND USES OF ON-TREATMENT IMAGING IN RADIOTHERAPY 24 MARCH 2015 LONDON MANAGEMENT AND RADIOLOGY - A GUIDE TO CURRENT AND FUTURE MANAGEMENT ISSUES IN RADIOLOGY 1 MAY 2015 LONDON AN EVENING WITH PROFESSOR LÁSZLÓ TABÁR: A NEW ERA IN THE DIAGNOSIS AND TREATMENT OF BREAST CANCER 11 MAY 2015 LONDON THORACIC IMAGING 15 MAY 2015 CAMBRIDGE IMAGING IN DEMENTIA 18 MAY 2015 LONDON EMERGENCY OUT OF HOURS RADIOLOGY 20 MAY 2015 GLASGOW NEURORADIOLOGY UPDATE AND REFRESHER COURSE 18-19 JUNE 2015 LONDON AN UPDATE IN CLINICAL BREAST MRI 23 JUNE 2015 LONDON FUNCTIONAL IMAGING IN RADIOTHERAPY 10 JULY 2015 LONDON ADVANCED TECHNIQUES IN CT 17 JULY 2015 LONDON IRMER UPDATE 28 SEPTEMBER 2015 BIRMINGHAM

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