The Healthcare Safety Investigation Branch (HSIB) has launched an investigation into case where a patient’s chest x-ray, showing a possible lung cancer, was not acted upon. The investigation team identified communication breakdown and failure to act on significant radiological findings as a priority patient safety risk for investigation.

The initial investigation identified that different systems and processes exist in different organisations to address the risk. The ongoing investigation will look at the human factors that impact the communication and follow up process, the variance in practice and the positive opportunities to learn from organisations that have implemented systems for improvement. 

Related downloads

Bulletin: communication and follow-up of unexpected significant radiological findings

View and download the bulletin below