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Getting order in systems

01 May 2007

Mr A, a 67-year-old publican, went to his local A&E department one Christmas. He complained of headache and diplopia, which had developed over a few hours, and had noticed slight weakness in his left hand. His wife commented that he had become more forgetful over the last few weeks and had difficulty working out the change for customers. He was a heavy smoker and had been diagnosed as having angina by his GP. Apart from a GTN spray, he was not taking any medication.

By the time Mr A was examined by Dr D his symptoms had improved. Apart from slight weakness in the left arm, the physical examination, including fundoscopy, was unremarkable. He was normotensive and in sinus rhythm. Routine blood tests, a chest x-ray and ECG were all normal. Dr D felt that the most likely diagnosis was a TIA (transient ischaemic attack) although he was concerned by the persistent diplopia and the history of memory loss. He referred Mr A to the Medical Admissions Unit, where he was seen by Dr K, the junior doctor on duty. He agreed with the diagnosis and arranged a CT scan for the following morning.

In the interim, Mr A was transferred to a medical ward for observation overnight. He felt much better the following day and was keen to go home to help his wife, who was running the pub. The hospital was particularly busy over the Christmas period and there was pressure to discharge patients. The scan was performed later that day by Dr E, the radiologist on-call. Dr E was not able to report the scan straight away. The patient was told that he could go home and that his GP would be contacted in due course with the result of his tests. He was advised to stop smoking and given an outpatient appointment to see a neurologist in four weeks.

Two weeks later, Mr A was found collapsed in the basement of the pub. He was readmitted to A&E where an emergency CT scan of his brain was performed. This showed a large cerebellar tumour with evidence of recent haemorrhage. There were signs of ventricular dilatation and raised intra-cranial pressure.

Arrangements were made to transfer Mr A to the local neurosurgical centre, but he died before this could be organised. It later transpired that no-one on the ward had looked at the report of the CT scan carried out during the first admission. This had shown a mass in the cerebellum “consistent with a primary or secondary neoplasm”.

Expert opinion

At the time, the hospital operated a mix of electronic and paper records. Although radiologists were using a computer-based system for reporting, it was common practice for them to write a short summary in the notes for inpatients. On this occasion, although the radiologist had completed a report on the system he had not written in the notes.

Expert opinion was critical of the system for communicating the results of scans and the fact that there was no mechanism to ensure that a report had been read or acted upon. The claim was settled for a moderate sum.

Learning points

  • There is an increased risk of communication failure when organisations use a combination of paper and electronic records. 
  • If an investigation has been ordered, systems should be in place to make sure that the result is checked and acted upon.
  • Although radiologists sometimes communicate urgent or unsuspected findings by phone or by writing in the case notes, this should not be relied upon as a sole reporting strategy.

Further information

In the UK, the National Patient Safety Agency (NPSA) issued a safer practice notice to ensure that radiological imaging reports are acted on. Between November 2003 and May 2006, the NPSA received 22 case reports where a failure to follow up radiological imaging reports led to fatalities or significant long-term harm. The NPSA called for healthcare organisations to ensure that results are communicated and acted on appropriately.

www.npsa.nhs.uk