Diagnostic Errors in Radiology

Lane F. Donnelly MD

Nemours Children’s Hospital

Human Performance

Mean

Human Performance

O’Boyle E, Aguinis H. Personnel Psychology 2012;65:79-119

Human Performance

633,263 researchers, entertainers, politicians, and athletes (amateur & professional)

Performance not a normal (Gaussian) distribution

Most accomplishment - by small group of super-performers

Human Peformance

Performance

People

Mean

Human Performance

O’Boyle E, Aguinis H. Personnel Psychology 2012;65:79-119

Conclusions

Most people are below average

What are those people going to do?

Be less productive

Make mistakes

Background IOM 1999 reports 44,000 to 98,000 deaths each

year due to medical errors > decade

Efforts: non-punitive error reporting, computerized order entry systems, bar coding, executive “walk rounds”, team training, simulation, specific interventions (central lines)

Societies (NQI, AHA, etc)

Non-government (TJC – National Patient Safety Goals)

Patient harm remains common, unchanged (multicenter study)

Landrigan CP et al. N Eng J Med 2010;363:2124-2134

Errors in Radiology

Faulty Data Gathering (wrong technique, wrong

patient, wrong side)

Perceptual Error (failed to see)

Faulty Information Processing (over / under

interpretation, faulty context, satisfaction of search)

Faulty Knowledge (insufficient knowledge, skill)

Communication (effective, timely, appropriate)

Taylor GA et al. Pediatr Radiol 2011;41:327-334

Pinto & Brunese. World J Radiol 2010;28:377-383

Renfrew et al. Radiology 1992:183:145-150

Agenda

Daily Management System

Standardization

Visibility

Data

Accountability & Policy

Daily Management Systems

Tiered Huddles Clinic Huddle Clinic Huddle

Outpatient

Huddle

Inpatient/Unit

Huddle

Integrated Huddle

OR

Huddle

ED

Huddle

Materials - Quality - IT - Lab - HR - Facilities - Radiology - Pharmacy - N1 - Training - Regulatory - Registration/Scheduling -

Facilities/Security - Finance - Family Centered Care - TLC - Rehab - Respiratory - HIM/UM - Business Network Development -

Marketing/Communications - Licensing/Credentialing - Research - Construction

Critical Care

Huddle

Patient Flow Huddle

Short (10 – 15 minutes)

Standing

Occur between 7AM – 9:30AM

At site of care

Front of visual board

Metrics / Readiness Assessment / Problem list

MESA

Huddles

No scheduled meetings 7 - 10:30 am

NCH leaders attend huddles

Observe operations (Gemba) during this time

NCH Leadership Standard Work

Nemours Children’s Hospital

Opened October 22, 2012

Integration Huddle started June 2012

Data tracked February 2013

Issues

252 Complex issues (28/month)

Sept - 21, Oct - 63, Nov – 73

After opening: flow (41), supplies (17), facilities (16), & IT (15)

Mean time to resolution = 19.1 days

– (0 – 125 days)

> 10 days (n = 9): IT (5), flow (2)

Agenda

Daily Management System

Standardization

Visibility

Data

Accountability & Policy

Standardization

Standard Work

Process Flow Maps

Check Lists

Value streams

Protocol (Evidence-Based)

Standardization – Value

Reliability of process

Executability of the process

Ability to detect abnormal states

Ability to study and improve

Understanding of those up & downstream from process

“Today’s standardization is the necessary

foundation on which tomorrow’s

improvement will be based. If you think of

“standardization” as the best you know

today, but which is to be improved

tomorrow – you get somewhere. But if

you think of standards as confining, then

progress stops.”

- Henry Ford 1926

Agenda

Daily Management System

Standardization

Visibility

Data

Accountability & Policy

Visibility – Visual Controls so that

Problems are not hidden

Visibility boards

Lead / solve issues in the workplace

5S (Sort, Straighten, Shine, Standardize, Sustain)

Integration Huddle – Metrics Board

Blue Bin System

The Logistics Center

Clinical Lab - January 2009

• High turnaround times

(avg 4 to 11 hours for stat)

• Drastic variability of

turnaround times (up to 24+

hours)

• Meeting STAT turn-

around-time goal of 1 hour

less than 20% of time

• Misplaced specimens

• High volume of customer

service calls (where’s my

result?)

Spaghetti Diagrams

Courier

Courier

Courier

2.25 miles

per shift 4.14 miles

per shift

Courier

Laboratory Performance Review

Agenda

Daily Management System

Standardization

Visibility

Data

Accountability & Policy

KPI Description: Time to Provider – time of pt arrival to time the MD/ARNP signs up for the

patient

Benchmark data suggests 30 minutes

Goal for 2012-2013 is 15 minutes

5/7/2013 KPI Owner:

Agenda

Daily Management System

Standardization

Visibility

Data

Accountability & Policy

How can safety be improved?

Horizontal Interventions

Culture or Environment

Vertical/Tactical Interventions

Process or Technology Adapted from © The Performance Group, 2006

Key Cultural Transformations

• Recognition: safety is an issue

• Everyone is accountable including

me

• Culture where people are

expected and encouraged to

speak up in the face of uncertainty

/ problems

Errors

Significant

events or

injuries

Adapted from Dr. James Reason, Managing the Risks of Organizational Accidents, 1997

Why Do Events Happen?

Three Types of Human Errors

Skill-Based Errors made when performing acts or tasks that require limited or

no thought attention

Rule-Based Errors made when performing acts or tasks that require

application of rules - accumulated through experience and training - to familiar situations

Knowledge-Based Errors made when performing acts related to new or unfamiliar

situations that requires problem solving and for which a rule does not exist or is not known

Standards of Behavior

Continuous Improvement

SOB #5: Be Curious Not Judgmental

“It’s about progress not perfection”

“Just Culture” – fix the system, not punish those reporting errors

Conscious Disregard

for Policy is Completely

Unacceptable

Expectations of Associates

Know Policy

Follow Policy

Speak up – problems or limitations of policy

Agenda

Daily Management System

Standardization

Visibility

Data

Accountability & Policy