Learning from events, errors, discrepancies, educational cases and good spots in clinical radiology

Sensible but effective processes need to be in place to ensure that all radiologists improve their own practice and the quality of the department by minimising the likelihood of repetition of errors and potential harm to patients.

This audit is worth carrying out because all doctors (including radiologists) make errors. Errors are inevitable but potentially avoidable. Sensible but effective processes need to be in place to ensure that discrepancies and errors are identified, shared with other radiologists for learning purposes and minimise the chance of repetition and hazard to patients. Failure to learn from a known problem or difficulty may well be perceived as a greater failure than the problem itself. This audit addresses several strategies to minimise error and its impact on patients. The Radiology Events and Learning Meetings (REALMs) will provide a forum for continuing education by learning from events, discrepancies, errors, educational cases and good spots. Cases may be submitted from retrospective random review, MDT feedback or double reporting in addition to routine peer text feedback (which will facilitate both positive feedback and areas for improvement).This audit is both valuable for individual radiologists’ revalidation as well as for departmental quality and safety.

The standard: 

1. Every radiologist should aim to attend at least 50% of REALMs and submit at least one case per year to the REALM for discussion 

2. The REALM should be held at least every 2 months (minimum of 6 meetings per year) 

3. There should be an identified chair/s of the REALM appointed and remunerated by the Trust

4. The cases discussed should be anonymised and discussed for education only

5. Learning points from each case discussed should be summarised and disseminated to all radiologists whether they attended the meeting or not

6. The chair should identify patterns of errors and target teaching accordingly

7. The chair should ensure submission of one case per year to the RCR REAL newsletter

Target: 

1. 50% attendance, 1 case per year submitted

2. ≥6 meetings/year

3. 100%

4. 100%

5. 100% cases summarised and disseminated

6. 100% of radiologists in the department receive the output

7. 1 targeted teaching session per year

8. 1 case submitted to REAL per year

Indicators: 

For each radiologist:

- Percentage of meetings attended

- Number of meetings/year 

- Number of cases submitted per year

- Number of targeted teaching sessions delivered in 5 years

- Register and log of REALM

Data items to be collected: 

- Attendance register and log of REALM

- Output summary of cases discussed

Suggested number: 

The audit involves all the radiologists and all the REALMs in one year

- Remind radiologists of their responsibility to attend errors meetings as part of clinical governance and that a personal record of attendance is required for the GMC folder for revalidation purposes

- Arrange protected time for the errors meetings as part of the monthly work programme and perhaps combine the regular monthly audit meeting (presentation of completed audits) with the errors meeting

- Identify staff member responsible for introducing change

- REALM lead to maintain the register of attendance and the log

- Clinical director (with the REALM lead) to scrutinise the attendance records and the log of cases shown in order to assess participation by each of the radiologists

1. Royal College of Radiologists. Standards for events and learning meetings  2019

Adapted from Clinical Governance and Ravalidation 2000 RCR updated by D Remedios in 2016. Further updated by Dr Jonathan Timothy Smith (Chair of REAL) in 2019