Audit Title: Communication of Urgent Reports

Descriptor: The policies that are in place for the communication of urgent or unexpected findings to the referrer.

Background:

The NHS National Patient Safety Agency have published Safer Practice Notice 16 following the receipt of 22 reports where the failure to follow up radiological imaging reports led to patient safety incidents, most of which involved fatalities or significant long term harm. Every department should provide a means for the communication of urgent reports as outlined by Safety Practice Notice 16. (Refs 1 and 3) The processes involved should be transparent and form clear available trust policy agreed between the radiology department and requesting clinicians. The processes involved should be subjected to regular audit.

The cycle:

THE STANDARD

The communication of the report of all cases of suspected malignancy should follow a defined ‘safety net’ procedure agreed locally for example, copy reports to the GP, cancer services multidisciplinary team or other identified health professional in consultation with the referring health professional.

National Local

Target

100%

LOCAL PRACTICE WAS ASSESSED AS FOLLOWS

• The indicator(s)

• Data items collected

• Number of patients / cases / episodes

SUGGESTIONS FOR CHANGE IF TARGET NOT MET

The Resources Used …

THE DATA was collected by ...

ÿ Computer records ÿ Review of requests ÿ Other (specify)

ÿ Review of images ÿ Ongoing data recording

ÿ Review of reports ÿ Questionnaire

ASSISTANCE

ÿ None ÿ Data analysis ÿ Other (specify)

ÿ Secretarial ÿ Software (off shelf)

ÿ Audit office ÿ Software (customised)

ÿ Medical records ÿ Clinical professionals

TIME to help complete stages 1–3 of the first cycle

R A D I O L O G I S T R A D I O G R A P H E R O T H E R ( s p e c i f y )

Approx _____ hrs per week Approx _____ hrs per week Approx _____ hrs per week

for _____ weeks for _____ weeks for _____ weeks

= total _____ hours = total _____ hours = total _____ hours

COSTS (stages 1–3 of the cycle) apart from radiologists’ / radiographers’ time

ÿ None/minimal ÿ Other (specify) Stages 1–3 of the first cycle

£

ÿ Temporary staff

ÿ Information technology

Results of the Completed Cycle…

• Local practice was re-assessed ____________ months after the changes were introduced

• Date of re-assessment

• Data items collected

• Assistance obtained from

• 

  £

  Costs (stages 5–6) of the re-audit (not including the cost of the changes)

Comparison of findings …

(a) with the standard, shows that ...

(b) with the previous audit findings, shows that ...

(c) indicates that an improvement on the previous audit findings has occurred ÿ Yes ÿ No

A Further Audit will Occur …

in months to start (date)

Useful References …

1.Early identification of failure to act on radiological imaging reports: National Patient Safety Agency Notice 16 2007
2. Communicating radiology results. L Berlin. The Lancet (2006), 367; 373-375.
3. Royal College of Radiologists. Guidelines for the Communication of Urgent Reports 2008

The Audit was carried out by …

Stages 1–4 Stages 5–6

Hospital

Address Telephone No:

Fax No:

A Copy of this form has been …

ÿ placed in the Department’s Audit File

ÿ sent to the Hospital’s Audit Office

ÿ sent to the Clinical Audit Unit at the RCR

Appendix …

Further information (audit design / questionnaire / analysis of results / introduction of change)

is included as follows ...

© The Royal College of Radiologists 2010