The lack of follow-up or communication of unexpected significant findings can have a serious or life-threatening impact on patients. This was seen in the reference case that informed this Healthcare Safety Investigation Branch (HSIB) investigation. In this event, a 76-year old woman had a chest X-ray showing a possible lung cancer which was not followed up and resulted in a delayed diagnosis. The patient died just over two months after her diagnosis.
The investigation identified that there:
- are multiple opportunities for error in the processes used to communicate unexpected findings
- are many steps that have to be completed successfully before the patient is informed
- is variance in how clinicians receive findings and how they acknowledge receipt of them.