Intended for healthcare professionals


Technology could provide safety net for scan and x ray results lost in the system

BMJ 2019; 366 doi: (Published 19 July 2019) Cite this as: BMJ 2019;366:l4778
  1. Adrian O’Dowd
  1. London, UK

Results from patient scans and x rays are sometimes lost and not acted on, with serious consequences, a report by the body that carries out independent investigations of patient safety concerns in NHS care in England has concluded.

To tackle this problem, the report by the Healthcare Safety Investigation Branch has recommended that patients be sent texts or emails suggesting they contact their GP if tests show abnormal results, as a safety net for results that go missing between different parts of the NHS.1

The agency carried out an England-wide investigation following the case of a 76 year old woman who had a chest x ray after a suspected heart attack. The x ray showed a possible lung cancer, but this was not followed up and resulted in a delayed diagnosis.

Although her cancer was detected by a radiologist, the diagnosis was passed between various clinical teams but did not reach the patient or her GP and the patient died just over two months after her diagnosis.

In its report, the agency said the lack of follow-up or communication of unexpected significant findings could have a serious or life threatening impact on patients.

Its investigation identified multiple opportunities for error in the processes used to communicate unexpected findings; many steps that have to be completed successfully before the patient is informed; and variance in how clinicians received findings and how they acknowledged receipt of them.

Technology could help, said the agency, which recommended that NHSX—the policy unit to support the use of technology in the NHS—work in conjunction with the Royal College of Radiologists to develop an automated, digital notification system to inform patients of a significant result to be discussed with them.

The notification would be sent within an agreed timeframe to ensure the majority of patients would have received the information from a clinician.

Other recommendations made by the investigation (also aimed at NHS England, NHS Improvement, and the Care Quality Commission) were to develop standardised ways in which results are graded as “unexpected significant,” “critical,” and “urgent,” and to create a list of conditions for which an alert should always be triggered.

Keith Conradi, chief investigator at the agency, said: “The organisations and people we have worked with are all committed to reducing the identified risks, and we are confident our safety recommendations will make a difference for patients across the country.”

The Royal College of Radiologists endorsed the report, saying it underlined “ongoing, widespread potential for patient harm.”

Mark Callaway, one of the advisors to the investigation and the college’s medical director of professional practice for clinical radiology, said: “Today’s report details a comprehensive, important investigation which shines a light on fundamental problems around patient follow-up and alerts within the NHS in England.

“These overarching problems are mainly a result of widespread local variation in IT and administrative capability and alert procedures, as well as patient handover procedures, all of which are crucial in ensuring radiological findings are flagged, acknowledged, and acted on.”

Simon Eccles, chief clinical information officer and deputy chief executive of NHSX, said: “NHSX is working to speed up care and improve patient safety by setting standards for the NHS so that hospital and GP IT systems talk to each other and essential information, like x ray findings, gets to where it’s needed as quickly as possible.”


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