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Early identification of failure to act on radiological imaging reports

Early identification of failure to act on radiological imaging reports
Reference number
0472
Central Alert System (CAS) reference
NPSA/2007/16
Issue date05 February 2007
Action date (if applicable) (date field)28 February 2008
DH Gateway reference
NPSA/2007/16
TypeAlert

This Safer Practice Notice advises healthcare organisations to make changes to ensure that radiology imaging results are communicated and acted on appropriately.

 

Radiology imaging tests are requested by a registered health professional who relies on a report and image usually generated by a radiologist or radiographer. These are sent to the referring health professional, who then acts on the result. This system is unreliable and has been proven to fail.

 

Between November 2003 and May 2006, the National Reporting and Learning Service (NRLS) received 22 reports where failure to follow up radiological imaging reports led to patient safety incidents, mostly involving fatalities or significant long-term harm. NHS Litigation Authority data for the 10 years to May 2006 included 69 cases, some of which involved significant harm and monetary claims.

 

The NRLS recommends that all healthcare organisations providing or commissioning radiological imaging services should:

 

  • ensure that all radiological imaging reports are communicated to, and received by, the appropriate registered health professional and that action is taken in a manner appropriate to their clinical urgency;
  • ensure registered health professionals design ‘safety net’ procedures for their specialty;
    make clear to patients how and when they should expect to receive diagnostic test results;
  • review relevant policies and procedures in line with the detailed recommendations outlined in the notice.
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