The Healthcare Safety Investigation Branch (HSIB) has released an interim bulletin relating to their investigation into the communication and follow-up of unexpected significant radiological findings. 

The investigation focuses on a case where a patient’s chest x-ray, showing a possible lung cancer, was not acted upon. 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. 

Interim bulletins are released to share further details of each investigation, including how it’s met HSIB criteria, the history of the event it relates to, the national context and any identified safety issues.

The HSIB launched its first full investigation in July 2017 and is now conducting 12 full investigations. 

Download the bulletin here