X-ray of a shoulder and chest.

Failures in communication or follow-up of unexpected significant radiological findings

HSIB legacy content

HSIB legacy content

This investigation was carried out by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

Background

X-rays are the most common radiological examination. 22.9 million were carried out in the NHS in 2016/17. Failures in communication or follow-up of unexpected significant radiological findings is a nationally recognised patient safety risk.

The lack of follow-up or communication of unexpected significant findings can have a serious or life-threatening impact on patients.

Reference event

In the investigation reference 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 national investigation

Failures in communication or follow-up of unexpected significant radiological findings is a nationally recognised patient safety risk.

HSIB contacted the hospital where the reference event occurred after it was reported as an incident on the national serious incident reporting database.

The investigation reviewed the processes for communication and follow-up of unexpected significant radiological findings to understand why such findings are not always received or acted upon.

The factors that influence the communication of results were explored and opportunities to reduce the risk of this happening in future were identified.

The investigation paid particular attention to unexpected significant radiological findings from chest X-rays performed during a patient’s stay in an emergency department (ED).

X-rays are the most common radiological examination and large volumes are requested from EDs. However, the conclusions of this investigation are applicable to the communication of radiological findings from other areas, and other types of diagnostic test results.

Findings

  • There is wide variation in practice in how unexpected significant radiological findings are communicated to clinicians. There is also considerable variation in how findings are acknowledged by clinicians, if they are at all. There is very little assurance that the actions indicated by the findings have been taken.
  • Unexpected significant radiological findings may be communicated by telephone, electronic or paper-based systems, and involve a variety of policies and procedures. It is often a multi-step process, involving a number of individuals and information systems; this increases the risk of errors.
  • Monitored acknowledgement of radiological findings is an important component of a reliable system and requires dedicated time and resource. Monitored acknowledgement is not in place in many trusts.
  • Opening a report and generating a read receipt is an unreliable form of acknowledgement. A more robust risk control is for acknowledgement to be a separate, distinct action. That said, acknowledgement does not guarantee action has been, or will be, taken. A system that provided assurance that necessary actions had been completed would best mitigate risk. Current IT infrastructure in many trusts means this is not feasible in the short term.
  • There are often many steps before a patient is informed of an unexpected significant radiological finding. These steps provide opportunities for error. Inspection of trusts by the Care Quality Commission is limited in scope in relation to the communication and follow-up of radiological findings. Inspections do not look at whether a monitored acknowledgement system and other risk controls necessary for a reliable system are in place.
  • There is no nationally agreed list of what constitutes an unexpected significant finding that should trigger an alert. Some trusts have developed lists to standardise when alerts should be triggered by radiologists and to create a common expectation for clinicians.

Impact

During our investigation we collaborated closely with the Royal College of Radiologists and the Academy of Medical Royal Colleges. They were integral to the development of our safety recommendations, which you can read in full below.

As a result of our safety recommendations, the Academy of Medical Royal Colleges published Recommendations on alerts and notification of imaging reports guidance in October 2022. The main objective of this guidance is to ensure prompt and effective imaging result notification and its subsequent action to protect patient safety.

This guidance reflects the evidence found in our investigation and fulfils our safety recommendation.

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Read the full report