This ‘Signal’ is about missed or delayed diagnosis (often older patients after a fall) of spinal fractures resulting in paralysis. See also related delayed diagnosis 'Signal': delayed diagnosis of testicular torsion.
Extract from incident reported to the RLS:
“CT reported as no other injury verbally to surgeons by on - call radiologist during the night. Fracture Tg mentioned in the report following day, but no mention of instability and potential spinal cord damage. Patient transferred to [Hospital B] without this information. Diagnosis of unstable fracture and spinal cord damage made at [Hospital B].”
Following three similar reports of neurological damage after a spinal fracture had been missed, the National Reporting and Learning Service (NRLS) searched all reports received and identified 34 similar incidents where delay in diagnosis of a spinal fracture may have led to paralysis.
The background to the delays varied. For some patients, spinal fracture had been considered as a possible diagnosis, but problems with interpreting x-rays or accessing scans had led to error.
For other patients (especially older patients with history of an apparently minor fall at home), a spinal fracture had not been considered initially, with their symptoms attributed to possible stroke or head injury. Because delayed diagnosis of spinal fractures have the potential to cause permanent disability, this is an area we are exploring further by reviewing litigation data and seeking advice from expert groups including the College of Emergency Medicine.
We would like to hear from you – please contact us with anonymised copies of local investigations or information about your initiatives to reduce risks in any of these areas.
Signals are notifications of key risks emerging from review of serious incidents reported and shared by the NRLS.
Related categories to: patient assessment/diagnosis, medicine, emergency medicine
Short Survey on the value and effectiveness of Signals
This is a pilot project. To assess the value and effectiveness of Signals, we would be grateful if you and your staff could take a few minutes to answer a short survey. We would like to know if you have found Signals useful and how it could be developed further to suit your needs.