19.07.19
HSIB report focuses on technology to reduce radiology risks
A report published today by HSIB has showcased where technology could play a pivotal role in reducing harm caused by failures in communication or follow-up of unexpected significant radiological findings.
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.
The investigation identified that there are multiple opportunities for error in the processes used to communicate unexpected findings; that there are many steps that have to be completed successfully before the patient is informed; and that there is variance in how clinicians receive findings and how they acknowledge receipt of them.
One of the recommendations 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.
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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.
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.”
The investigation also makes three other recommendations in relation to following up unexpected significant radiological findings.