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,
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http://asrs.arc.nasa.gov/overview/summary.html. Accessed March 7,
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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
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