Anatomy of an Error

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This morning’s sessions on quality improvement continued with Jonathan Kruskal, MD, PhD, focusing on safety and risk management in radiology. His presentation, “Anatomy and Pathophysiology of Radiological Errors,” kicked off with a quote from AJR: “It is not the occurrence of error that is damning, but the failure to seize on it as an opportunity for improvement.”

So: what constitutes an error? According to Kruskal, it’s any deviation from the expected norm, irrespective of the outcome. “In other words, if you miss a small sclerotic lesion but it’s of no consequence to the patient, that’s still an error,” he said. “It’s a symptom of a flawed underlying process.”

Kruskal says there are a number of commonly accepted myths about errors, all untrue – including the notion that all errors are bad, that errors occur randomly, and that errors are rare among trained professionals. He also noted that it is not always easier to change people than situations, another common misconception: “When something goes wrong, it’s easy to identify who made the error,” he said. “But there are often plenty of other associated factors that contributed to that error.”

The first step toward minimizing errors is having error detection mechanisms in place, which often requires a major cultural change, requiring staff members to report both their own errors and those of others. At Kruskal’s facility, this process took over three years to implement, but today, he reports, his staff is diligent about reporting and addressing their own errors. Harm reduction is a second issue, requiring that any error that might cause harm is reported to the patient and other involved parties.

There are a few different categories of error, Kruskal said, but to break it down simply, it’s best to think of two types: human or active errors, i.e. those caused by patients or practitioners; and latent or systems processes errors, which include technical and organizational issues. “If you think of the patient as being central to everything we do, it’s easier to break down human errors,” he said. “They could come from radiologists, primary care physicians, techs or nurses, support staff.”

In order for an error to occur, several failures must occur at once: a human error coupled with one or more latent errors, aligning to create the perfect storm, as it were. “You do a catheter insertion and something goes wrong,” Kruskal said. “There are a number of latent contributors: you may not have been properly trained; the technologist might not be experienced enough; the original requisition form could’ve been unavailable; you didn’t mark the site; you didn’t verify the ID of your patient. All these factors could contribute to the error.”

Active errors in radiology can be classified by six root causes:

--Underreading
--Complacency
--Faulty reasoning
--Lack of knowledge
--Poor communication
--Complications

But in order to minimize errors, Kruskal recommends cutting down on latent issues first: getting rid of ambient light, redirecting phone calls outside of the reading room to cut distractions, creating separate spaces for teaching rounds, and so on.

The last aspect of the issue he touched on was the impact of errors. From a medical perspective, that would be the physical impact on the patient; but there’s also a psychological impact on the radiologists themselves. “This is often an unanticipated consequence of error,” Kruskal said, “and you need processes in place to address it.”

Kruskal closed with this thought: “For an error to occur, a constellation of contributing factors is usually present, but good detection and analytical processes can minimize the occurrence of subsequent errors.”