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Transferring neurosurgery patient images | Signal

Reference number
1162 B
Issue date26 February 2010

This Signal relates to problems with accessing images in neurosurgery within and between centres leading to delay in treatment.


Imaging is essential for the diagnosis and treatment of patients with disorders of the brain and nervous system. Prompt and accurate image interpretation is needed for surgery following trauma (such as head injury) or other urgent conditions such as tumours or haemorrhages in the brain or spinal cord. Timely diagnosis is crucial and expert opinion may be needed from one of the regional neurosurgical centres. Many of these patients will be emergency cases, where delays in accessing images within and between hospitals can cause patient harm. 


A typical incident report reads:
“Had call from ******* hospital to provide urgent opinion (as neurosurgical registrar) for patient with large brain haemorrhage. Attempted access of digital CT scans (already linked by radiology dept in *****) with radiology link system. Unable to access images. Thus delay in making decision regarding appropriate management of patient with potentially life-threatening condition.”


Following a trigger incident, the National Reporting and Learning Service (NRLS) identified 15 incidents from the Reporting and Learning System (RLS) database which had the potential to cause serious harm (exact outcome often unknown) because of delayed treatment due to problems transferring images. This information was shared with the Society of British Neurological Surgeons who confirmed that this was a real problem which was under-reported by staff. A meeting was convened by the NRLS between the neurosurgeons and Connecting for Health.


The issue was referred to the Clinical Board for Surgical Safety in January 2010. There was a useful discussion, with input from a number of clinicians and Dr Tony Newman-Sanders, National Clinical Advisor for Patient Safety at the Connecting for Health PACS Programme. It was agreed that the national Picture Archiving and Communication System (PACS) systems, launched by Connecting for Health from 2005 to improve the capture of digital X-rays and scans, had brought benefits but some problems remain.


Evidence from published national surveys reviewed at the meeting suggests that around 60 per cent of admitting neurosurgical units still receive urgent images via road couriers or taxis. A local audit of one month’s referrals to a London tertiary centre showed that, on average, images took more than five hours to arrive by courier as opposed to six minutes by digital transfer. Other problems included data confidentiality issues, resilience 24/7 (including home/remote access for on-call specialists outside hospital setting) and problems in encrypting and accessing images. This applied to specialties other than neurosurgery, but the acute nature of neurosurgical patients and urgency of intervention made this a useful patient safety concern to highlight.


Dr Newman-Sanders reported that many of these problems are being addressed by regional tactical solutions, but that a national image routing system, the image exchange portal (IEP), would offer significant improvements. This recommendation has been strongly supported by the Clinical Board for Surgical Safety.


Have you had problems in transferring or accessing urgent images?


Continue to report adverse incidents through your local risk management systems. For support and/or issues around PACS contact the Connecting for Health helpdesk.


Relevant to: information, diagnosis, surgery



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