From the Cardiothoracic Imaging Division, Department of Radiology, University of Michigan, Taubman Center B1-132D, 1500 E Medical Center Dr, Ann Arbor, MI 48109-5302 (M.M.H.S., E.C.S., G.E.M., L.E.Q., P.P.A.); and Abdominal Imaging Division and Michigan Radiology Quality Collaborative, Department of Radiology, University of Michigan, Ann Arbor, Mich (P.R.S.).
Radiographics. 2022 Mar-Apr;42(2):579-593. doi: 10.1148/rg.210125. Epub 2022 Feb 11.
Medical errors may lead to patient harm and may also have a devastating effect on medical providers, who may suffer from guilt and the personal impact of a given error (second victim experience). While it is important to recognize and remedy errors, it should be done in a way that leads to long-standing practice improvement and focuses on systems-level opportunities rather than in a punitive fashion. Traditional peer review systems are score based and have some undesirable attributes. The authors discuss the differences between traditional peer review systems and peer learning approaches and offer practical suggestions for transitioning to peer learning conferences. Peer learning conferences focus on learning opportunities and embrace errors as an opportunity to learn. The authors also discuss various types and sources of errors relevant to the practice of radiology and how discussions in peer learning conferences can lead to widespread system improvement. In the authors' experience, these strategies have resulted in practice improvement not only at a division level in radiology but in a broader multidisciplinary setting as well. RSNA, 2022.
医疗差错可能导致患者伤害，也可能对医疗服务提供者造成毁灭性影响，他们可能会感到内疚，并受到特定错误（第二受害者体验）的个人影响。虽然认识和纠正错误很重要，但应该以导致长期实践改进和关注系统层面机会的方式进行，而不是以惩罚的方式进行。传统的同行评审系统是基于评分的，并且具有一些不理想的属性。作者讨论了传统同行评审系统和同行学习方法之间的区别，并为过渡到同行学习会议提供了实用建议。同行学习会议侧重于学习机会，并将错误视为学习的机会。作者还讨论了与放射科实践相关的各种类型和来源的错误，以及同行学习会议中的讨论如何导致广泛的系统改进。根据作者的经验，这些策略不仅在放射科的一个部门层面，而且在更广泛的多学科环境中都导致了实践的改进。RSNA，2022.
