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Latest HSIB report focuses on technology to reduce risk of X-ray findings getting lost

by Communications team

A report published today (18 July) by HSIB showcases where technology could play a pivotal role in reducing harm caused by failures in communication or follow-up of unexpected significant radiological findings

Serious impact on patients

The lack of follow-up or communication of unexpected significant findings can have a serious or life-threatening impact on patients. This was seen in the reference case that informed the investigation. In that event, a 76-year old woman had a chest X-ray showing a possible lung cancer which was not followed up and resulted in a delayed diagnosis. The patient died just over two months after her diagnosis.

Multiple opportunities for error

The investigation identified that there:

  • are multiple opportunities for error in the processes used to communicate unexpected findings
  • are many steps that have to be completed successfully before the patient is informed
  • is variance in how clinicians receive findings and how they acknowledge receipt of them.

One of the recommendations in the report has been made to NHSX, to work in conjunction with the Royal College of Radiologists to develop an automated, digital notification to inform patients of a significant result to be discussed with them. 

The notification would be sent within an agreed timeframe to ensure that the vast majority of patients would have received the information by a clinician. However, if the result had become lost in the system for any reason, the notification would provide a vital safety net and ensure the most important person – the patient – was made aware of the result. 

Chief Investigator’s view

Keith Conradi, Chief Investigator, commented: “In this investigation, we recognised the shift in culture towards people having full access to their health information but also the need to balance the personal approach with technological solutions, especially when findings are unexpected.

“In our reference case, the patient’s husband expressed his regret at the missed opportunities for his wife. He wanted to be part of our investigation to help prevent the same thing happening again. The organisations and individuals we have worked with on this investigation are all committed to reduce the identified risks, and we are confident our safety recommendations will make a difference for patients across the country.”

Safety recommendations

The investigation also makes three other recommendations in relation to following up unexpected significant radiological findings, to The Royal College of Radiologists, NHS England and NHS Improvement, and the Care Quality Commission.

Read the safety recommendations in full on the communication and follow up of unexpected significant radiological findings investigation page.

Responses to the recommendations will be published on the HSIB website later this year.

Read the report

Download and read the ‘Failures in communication or follow-up of unexpected significant radiological findings’ investigation report.

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