Putting Patient Safety at the Center of Radiology Residency
QI initiative boosts resident engagement in safety practices
Radiology residents are key contributors to the clinical workforce, and their training is essential for ensuring high-quality care.
At the heart of quality care is patient safety—a topic that, according to Nelly Tan, MD, is often missing from the residency program. “We know how to do diagnostics; we know how to do procedures, but when it comes to patient safety, it’s just not part of our training,” said Dr. Tan, an abdominal radiologist at Mayo Clinic Arizona.
This is in part why the Accreditation Council for Graduate Medical Education (ACGME) requirements have been expanded to include such activities as root cause analyses (RCAs) and participating in safety initiatives.
But complying with these requirements is easier said than done.
That’s why, when the Mayo Clinic’s 16 radiology residents showed a compliance rate that was below the ACGME standard, the hospital decided to pursue a quality improvement (QI) project.
It Starts with Education and Training
To start, a team of radiology residents, leaders and QI professionals used the Lean Six Sigma DMAIC to identify the root causes of low resident participation in safety event investigations. DMAIC (Define, Measure, Analyze, Improve, Control) is a formal framework used in QI initiatives.
“Although residents are required to participate in quality improvement projects, they often receive limited education and training on QI methodology,” explained Lisa Ponce, MS, RT(R), a radiology quality improvement advisor at Mayo Clinic. “Furthermore, residents typically do not participate in root cause analyses (RCAs) or safety event investigations unless they are directly involved in the event.”
In response to these findings, the team implemented targeted interventions aimed at restoring compliance with ACGME standards. Interventions included improving safety event reporting education and incorporating simulated RCA events, among others.
To improve safety event reporting education, the QI team found that although the patient safety education material existed, residents didn’t know how to access it. To remedy this, the team created a shared directory to provide easy access to the materials and ensured that all residents were aware of its existence.
“By simply providing quick access to these educational resources we were able to facilitate continuous learning for residents,” Dr. Tan said.
RCA Simulations Boost Resident Confidence
Recognizing that residents would benefit from more training that included hands-on experience in conducting RCAs, the QI team also developed an annual mock RCA.
Designed to meet ACGME requirements, the simulation was fully implemented in 2024 to provide residents and fellows with ongoing opportunities for hands-on experience. This was done in addition to or in lieu of participating in a genuine patient safety event review.
The mock cases draw on themes and lessons from multiple real RCAs and are modified to create realistic scenarios residents could encounter in practice. According to Dr. Tan, the simulations conducted by the radiology QI team are designed to demonstrate the procedure of investigating safety events.
The effectiveness of the mock RCA was assessed based on participant feedback and the quality of the analysis performed during the simulation. Preliminary outcomes showed strong resident engagement and improved confidence in conducting RCA discussions.
“Although based on real high-risk cases, these simulations create a low-risk, safe environment that encourages residents to slow down, ask questions and really become familiar with the process so when it’s time to do a real RCA, they’re confident and ready to go,” Dr. Tan said.
Reshaping How Residents Think About Patient Safety Events
According to one resident, the simulated RCA was particularly impactful. “Residents are not typically involved in real RCAs to preserve anonymity, so this was a unique learning opportunity,” said Logan Haug, MD, now a musculoskeletal radiology fellow at Mayo Clinic.
The case Dr. Haug participated in involved a delayed diagnosis of a pneumothorax, an event that, at first glance, could be easily attributed to an individual error like a missed post-procedural chest X-ray order. However, the RCA process emphasized evaluating both individual actions and system-level factors that could contribute to the error.
This challenged residents to consider system-level fixes, such as modifying the EMR to prompt or automate post-procedural imaging when orders are missed, reducing the risk of recurrence.
“This systems-based perspective was very insightful and reshaped how I think about patient safety events,” Dr. Haug said.
Dr. Haug was also involved in designing the QI project—an experience he said was particularly valuable as it highlighted the breadth of thought required for a successful QI project, from initial problem synthesis and baseline data acquisition to implementation and measuring outcomes.
“I hadn't previously considered many of the factors involved in the process, such as the importance of balancing measures to ensure that fixing a quality gap doesn't result in increased workload or in delays in other domains,” he said.
From a career perspective, Dr. Haug said that both the overall QI process and the RCA experience will be highly beneficial. “The project provided a structured framework for developing and executing a QI initiative, and I now feel significantly more confident in identifying opportunities and leading similar efforts in the future,” he said.
An Interdisciplinary Approach to Patient Safety
For clinics looking to implement similar initiatives to improve patient safety education for radiology residents, Ponce recommends including all relevant stakeholders early and having appropriate sponsors to support sustainability and approve any interventions or changes.
“This is a great opportunity to bring people together—the radiology residents and fellows, technologists, nurses and attending physicians—to experience the benefits of taking an interdisciplinary approach to patient safety,” Ponce said.
It’s also important to work around resident schedules to allow for more frequent project meetings, which in turn helps maintain momentum, improve communication and increase team engagement.
Supporting Resident Engagement in Patient Safety
Taking a systematic approach with structured education and tracking systems, Mayo Clinic improved resident participation in patient safety activities. In doing so, they also strengthened their culture of safety and improved multidisciplinary collaboration and communication.
“With these benefits in mind, we highly encourage other residency programs and healthcare settings to consider similar interventions to support resident engagement in patient safety,” Ponce concluded.
For More Information
Access the Current Problems in Diagnostic Radiology article, “Improving patient safety education for radiology residents: Using a quality improvement approach.”
Read previous RSNA News stories on safety:
Preparing Residents for On Call
The Mayo Clinic is but one example of how hospitals are working to improve the quality of their resident training. In Canada, the radiology department at the Ottawa Hospital is also leveraging training and simulations, not for RCAs but for independent on call duties.
The program primarily consists of a two-day course that is made available to residents shortly before they start independent on calls. “The virtual course provides a set of structured lectures to prepare residents for their on-call duties,” said Haruto Sugawara, MD, PhD, a radiologist at Ottawa Hospital who both organizes and conducts the course.
Unlike the on-site training given by a senior radiologist, Dr. Sugawara said the course looks to provide structured, knowledge-based training. “It is meant to help bridge the gap between shadowing a senior resident during calls and handling these calls by themselves,” he said.
For instance, during the course, residents learn how to prioritize imaging findings. “Residents may need to interpret up to 50 CTs in a single night, which can be overwhelming when just starting on-call duties,” Dr. Sugawara explained. “Our course helps them understand what to look for and how to prioritize.”
Dr. Sugawara said that such practical training helps build resident confidence. “Our residents have reported feeling safer, more confident and better supported before taking independent call, thanks in part to our course,” he concluded.