Rethinking peer review: what aviation can teach radiology about performance improvement.

David B Larson; John J Nance

Commentary

Rethinking peer review: what aviation can teach radiology about performance improvement.

August 31, 2011

Larson DB, Nance JJ. Radiology. 2011;259(3):626-32.

View more articles from the same authors.

This commentary explores how lessons from aviation can guide safety improvement in radiology.

PubMed citation

Available at

Related Resources From the Same Author(s)

Peer feedback, learning, and improvement: answering the call of the Institute of Medicine report on diagnostic error.

December 7, 2016

Crossing to safety: transforming healthcare organizations for patient safety.

April 15, 2005

Community-, healthcare-, and hospital-acquired severe sepsis hospitalizations in the University HealthSystem Consortium.

September 2, 2015

Choosing your words carefully: how physicians would disclose harmful medical errors to patients.

August 16, 2006

Lessons learned from implementing a principled approach to resolution following patient harm.

January 9, 2019

Pharmacy mixes up prescriptions.

February 16, 2011

Medication errors in pediatrics—the octopus evading defeat.

March 6, 2005

Weaving quality improvement and patient safety skills into all levels of medical training: an annotated bibliography.

April 23, 2014

Approaching the evidence basis for aviation-derived teamwork training in medicine.

October 28, 2009

Health care governance for quality and safety: the new agenda.

June 20, 2007

The attitudes and experiences of trainees regarding disclosing medical errors to patients.

March 19, 2008

How trainees would disclose medical errors: educational implications for training programmes.

April 13, 2011

Annotated bibliography: an update to: "Understanding ambulatory care practices in the context of patient safety and quality improvement."

July 21, 2020

Training in quality and safety: the current landscape.

August 27, 2014

Graduate medical education's new focus on resident engagement in quality and safety: will it transform the culture of teaching hospitals?

August 6, 2014

The evolving curriculum in quality improvement and patient safety in undergraduate and graduate medical education: a scoping review.

February 15, 2023

John M. Eisenberg Patient Safety Awards. Safety, effectiveness, and efficiency: a Web-based virtual anticoagulation clinic.

March 6, 2005

The occurrence of wrong-site surgery self-reported by candidates for certification by the American Board of Orthopaedic Surgery.

March 29, 2012

Effect of short-term pretrial practice on surgical proficiency in simulated environments: a randomized trial of the "preoperative warm-up" effect.

February 18, 2009

Distractions and surgical proficiency: an educational perspective.

January 20, 2010

Eliminating preventable death at Ascension Health.

March 14, 2007

When should a multicampus hospital be considered a single entity for public reporting on patient safety issues?

June 6, 2007

Confusion about epinephrine dosing leading to iatrogenic overdose: a life-threatening problem with a potential solution.

May 12, 2010

The prevalence of medical error related to end-of-life communication in Canadian hospitals: results of a multicentre observational study.

November 25, 2015

Culture change at the source: a medical school tackles patient safety.

January 31, 2006

Health care provider use of private sector internal error-reporting systems.

November 30, 2005

The quality of pharmacologic care for vulnerable older patients.

March 6, 2005

Development and evaluation of a 1-day interclerkship program for medical students on medical errors and patient safety.

January 31, 2007

Patient safety during sedation by anesthesia professionals during routine upper endoscopy and colonoscopy: an analysis of 1.38 million procedures.

April 20, 2016

Advanced practice nursing students' identification of patient safety issues in ambulatory care.

April 10, 2013

Requirements for implementing a 'just culture' within healthcare organisations: an integrative review.

June 21, 2023

National cluster-randomized trial of duty-hour flexibility in surgical training.

February 10, 2016

Potassium and phosphorus repletion in hospitalized patients: implications for clinical practice and the potential use of healthcare information technology to improve prescribing and patient safety.

February 14, 2007

Assessment of patients' ability to review electronic health record information to identify potential errors: cross-sectional web-based survey.

March 10, 2021

Association of the 2011 ACGME resident duty hour reform with general surgery patient outcomes and with resident examination performance.

January 14, 2015

The clinical transformation of Ascension Health: eliminating all preventable injuries and deaths.

June 7, 2006

Have you M.E.T. the future of better patient safety?

October 26, 2005

Association of the 2011 ACGME resident duty hour reform with postoperative patient outcomes in surgical specialties.

August 12, 2015

Effect of illness severity and comorbidity on patient safety and adverse events.

November 9, 2011

Physician burnout and medical errors: exploring the relationship, cost, and solutions received.

August 9, 2023

Patient safety issues in advanced practice nursing students' care settings.

November 9, 2011

Medically-necessary, time-sensitive procedures: a scoring system to ethically and efficiently manage resource scarcity and provider risk during the COVID-19 pandemic.

May 6, 2020

A comparison of hospital adverse events identified by three widely used detection methods.

August 5, 2009

Discrimination, abuse, harassment, and burnout in surgical residency training.

November 20, 2019

Every error a treasure: improving medication use with a nonpunitive reporting system.

July 18, 2007

Emergency medicine quality improvement and patient safety curriculum.

November 17, 2010

Implementing patient safety practices in small ambulatory care settings.

July 19, 2006

Hospice diagnosis: polypharmacy—a teachable moment.

October 7, 2015

Lessons learned from a systems approach to engaging patients and families in patient safety transformation.

February 12, 2020

Prevalence, types, and sources of bullying reported by US general surgery residents in 2019.

June 17, 2020

Relationship between patient safety climate and standard precaution adherence: a systematic review of the literature.

November 25, 2015

A survey of the use of time-out protocols in emergency medicine.

May 25, 2011

A high-reliability organization framework for health care: a multiyear implementation strategy and associated outcomes.

November 4, 2020

Isolation precautions for visitors.

April 29, 2015

An effective intervention: limiting opioid prescribing as a means of reducing opioid analgesic misuse, and overdose deaths.

September 23, 2020

ASHP guidelines on remote medication order processing.

July 7, 2010

Application of surgical safety standards to robotic surgery: five principles of ethics for nonmaleficence.

April 2, 2014

Status of the implementation of the World Health Organization multimodal hand hygiene strategy in United States of America health care facilities.

May 7, 2014

Outcomes of missed diagnosis of pediatric appendicitis, new-onset diabetic ketoacidosis, and sepsis in five pediatric hospitals.

September 13, 2023

Procedural safety in emergency care: a conceptual model and recommendations.

October 24, 2012

Perception of patient safety culture in pediatric long-term care settings.

February 13, 2019

Error disclosure and family members' reactions: does the type of error really matter?

February 18, 2015

Impact of patient safety climate on infection prevention practices and healthcare worker and patient outcomes.

May 10, 2023

Failure to engage hospitalized elderly patients and their families in advance care planning.

April 10, 2013

Outcomes of concurrent operations: results from the American College of Surgeons' National Surgical Quality Improvement Program.

October 11, 2017

Indication alerts to improve problem list documentation.

January 26, 2022

Determining the skills needed by frontline NHS staff to deliver quality improvement: findings from six case studies.

June 8, 2022

Where are my instruments? Hazards in delivery of surgical instruments.

August 10, 2016

Association of registered nurse and nursing support staffing with inpatient hospital mortality.

September 25, 2019

Financial incentives to reduce hospital-acquired infections under alternative payment arrangements.

March 28, 2018

'My five moments for hand hygiene': a user-centred design approach to understand, train, monitor and report hand hygiene.

November 14, 2007

Comparative safety of endovascular aortic aneurysm repair over open repair using Patient Safety Indicators during adoption.

July 23, 2014

Differences in safety climate among hospital anesthesia departments and the effect of a realistic simulation-based training program.

February 20, 2008

Medical and surgical comanagement after elective hip and knee arthroplasty: a randomized, controlled trial.

March 6, 2005

Patient safety climate among orthopaedic surgery residents.

July 6, 2011

Surgical confusions in ophthalmology.

November 14, 2007

Medical groups' adoption of electronic health records and information systems.

October 5, 2005

Receipt of antibiotics in hospitalized patients and risk for Clostridium difficile infection in subsequent patients who occupy the same bed.

October 19, 2016

Infection control hazards and near misses reported by nursing students.

January 5, 2011

A framework for patient safety: a defense nuclear industry-based high-reliability model.

May 1, 2013

Selecting indicators for patient safety at the health system level in OECD countries.

September 20, 2006

Effect of genetic diagnosis on patients with previously undiagnosed disease.

November 7, 2018

Potentially harmful medication dispenses after a fall or hip fracture: a mixed methods study of a commonly used quality measure.

March 9, 2022

Teaching internal medicine residents quality improvement and patient safety: a lean thinking approach.

April 28, 2010

Patient safety climate: variation in perceptions by infection preventionists and quality directors.

September 28, 2011

Relationship between systems-level factors and hand hygiene adherence.

June 9, 2010

Unintended doses in radiotherapy—over, under and outside?

April 18, 2018

Management of anesthesia equipment failure: a simulation-based resident skill assessment.

August 19, 2009

Mislabeled units of umbilical cord blood detected by a quality assurance program at the transplantation center.

October 14, 2009

Quality and safety implications of emergency department information systems.

July 17, 2013

Effect of antiseptic handwashing vs alcohol sanitizer on health care-associated infections in neonatal intensive care units.

May 4, 2005

The relationship between perceived practice quality and quality improvement activities and physician practice dissatisfaction, professional isolation, and work-life stress.

August 5, 2009

Improving handoffs in the emergency department.

October 28, 2009

The state of health, burnout, healthy behaviors, workplace wellness support, and concerns of medication errors in pharmacists during the COVID-19 pandemic.

August 23, 2023

ACR guidance document on MR safe practices: 2013.

March 21, 2013

Association of surgical resident wellness with medical errors and patient outcomes.

May 6, 2020

Introductions during time-outs: do surgical team members know one another's names?

May 24, 2017

Using a quantitative risk register to promote learning from a patient safety reporting system.

February 4, 2015

Advancing the next generation of handover research and practice with cognitive load theory.

January 27, 2016

How prevalent are hazardous attitudes among orthopaedic surgeons?

May 27, 2015

Related Resources

Quality and Safety in Health Care.

August 13, 2023

Patient Safety Innovations

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

July 31, 2023

Reducing errors resulting from commonly missed chest radiography findings.

May 31, 2023

Diagnostic errors in musculoskeletal oncology and possible mitigation strategies.

May 24, 2023

Neuroradiology diagnostic errors at a tertiary academic centre: effect of participation in tumour boards and physician experience.

August 17, 2022

An evolution of reporting: identifying the missing link.

August 10, 2022

Error and cognitive bias in diagnostic radiology.

April 13, 2022

Preventing and mitigating radiology system failures: a guide to disaster planning.

February 2, 2022

The perfect storm: exam of a medical error and factors contributing to its possible escalation.

June 23, 2021

ACR guidance document on MR safe practices: updates and critical information 2019.

August 14, 2019

Chasing zero harm in radiation oncology: using pre-treatment peer review.

May 22, 2019

Structural racism--a 60-year-old black woman with breast cancer.

April 10, 2019

Overcoming human barriers to safety event reporting in radiology.

March 6, 2019

Fundamentals of diagnostic error in imaging.

October 10, 2018

Focus On: Health Care Policy and Quality.

December 6, 2017

Systemic error in radiology.

August 9, 2017

Key principles in quality and safety in radiology.

May 3, 2017

Radiology research in quality and safety: current trends and future needs.

April 19, 2017

Infusion medication error reduction by two-person verification: a quality improvement initiative.

February 1, 2017

Overuse of medical imaging and its radiation exposure: who’s minding our children?

September 28, 2016

Society of Interventional Radiology IR Pre-Procedure Patient Safety Checklist by the Safety and Health Committee.

June 15, 2016

Collective intelligence meets medical decision-making: the collective outperforms the best radiologist.

September 9, 2015

Risk management in radiology departments.

July 15, 2015

Planning an MR suite: what can be done to enhance safety?

May 6, 2015

Practice and quality improvement: successful implementation of TeamSTEPPS tools into an academic interventional ultrasound practice.

March 11, 2015

FOCUS: The Society of Cardiovascular Anesthesiologists' initiative to improve quality and safety in the cardiovascular operating room.

October 22, 2014

Diagnostic errors in interpretation of pediatric musculoskeletal radiographs at common injury sites.

June 25, 2014

Emergency department image interpretation accuracy: the influence of immediate reporting by radiology.

June 4, 2014

Banning the handshake from the health care setting.

May 28, 2014

Fool me twice: delayed diagnoses in radiology with emphasis on perpetuated errors.

May 14, 2014

See More About The Topic

Health Care Providers

Quality and Safety Professionals

Radiology

Quality Improvement Strategies

Rethinking peer review: what aviation can teach radiology about performance improvement.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Rethinking peer review: what aviation can teach radiology about performance improvement.

Ambulatory Safety Nets to Reduce Missed and Delayed Diagnoses of Cancer

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site