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Follow-up of X-ray results (15HDC00268)
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(15HDC00268, 2 March
District health board ~ Follow-up
of results ~ X-ray ~ Delayed diagnosis ~ Lung mass ~ IT System ~
A woman went to an emergency department (ED) because she had
been experiencing a cough and chest tightness for about four days.
She was examined by a doctor who gave the woman nebulisers, after
which she was noted as being much improved.
The doctor ordered an X-ray of the woman's chest and did not
note anything of concern. She diagnosed chronic obstructive
pulmonary disease with acute asthma. The woman was discharged
home with her care discharged to her GP. Her discharge report did
not mention a pending X-ray report.
Later that month, the formal radiologist's report was sent
electronically to the doctor's inbox. In the report, the
radiologist identified a mass and recommended a chest X-ray or a CT
scan in six weeks' time.
Two days later the doctor reviewed the X-ray report. The doctor
was going away on leave the following day for ten days, and she did
not acknowledge the X-ray report. She said the results were not
immediately urgent, and she considered it appropriate to action
them on her return. She assumed the X-ray report would still be
visible in the memo tab of her inbox on her return, and was not
aware the memo would drop off from the view of the memo tab
after 24 hours.
When the doctor returned from leave, the X-ray report was no
longer visible in the memo tab of the doctor's inbox and the doctor
did not recall the report. The woman did not receive the
recommended follow-up X-ray or CT scan, and the X-ray results were
not sent to her.
About 20 months after the woman's X-ray, she returned to
hospital having felt unwell for the last few days. A review of her
electronic clinical history resulted in the discovery of the
non-actioned X-ray report which showed a mass on the woman's lung.
Sadly, two months later, the woman died.
The district health board's (DHB) IT system allowed results to
disappear from the view of the clinician's memo tab. Once results
were opened/viewed in the memo tab, after 24 hours (regardless of
whether they were acknowledged) they dropped to the bottom of the
queue. All unattended and unacknowledged reports remained in the
clinician's 'unacknowledged work list', however, the ED staff were
using only the memo tab.
It was found the DHB failed to have in place an appropriate
system for the management and acknowledgement of test results.
While a system was in place, clinicians were not trained adequately
to use the system. There was clearly widespread misunderstanding
within the DHB's ED regarding the functionality of the IT system,
which clinicians should have been able to rely on and use
adequately. This failure resulted in the doctor not following up on
the woman's report.
In addition, the DHB did not have in place an appropriate system
to ensure the woman's GP received the X-ray report, and did not
have a process to ensure reports or results did not go
unacknowledged by the clinicians. Accordingly, it was found the DHB
failed to provide the woman with an appropriate standard of care
and breached Right 4(1).
Adverse comment was made about the doctor not putting in place
any safety-netting strategies. However, overall it was considered
reasonable for her to rely on the system in these
It was recommended that the DHB:
a) Provide a report regarding the
outcome of the Electronic Acknowledgement Project to HDC and DHB
b) Provide an audit of four
months' data regarding the time taken to acknowledge reports.
c) Consider having a warning
system added to its Electronic IT system to alert clinicians to the
existence of unacknowledged results.
d) Arrange for an impartial IT
expert with a medical background to examine its electronic
management system to determine whether user warnings and updates
need to be built in to the software and training sessions.
e) Provide a report to HDC
regarding the actions taken in respect of the recommendations as
outlined in the DHB's Serious Adverse Event review.
f) Provide a written apology
to the woman's family.