Communication of Urgent Reports
The policies that are in place for the communication of urgent or unexpected findings to the referrer.
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 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.
100%
-
The indicator
a. Communication of possible malignancy in a report by clearly agreed pathways.
b. All patients with a possible malignant diagnosis are referred appropriately.
-
Data items to be collected
Choose a site specific cancer (e.g. Lung) and ask for a list of referrals from the MDT for the past three months.
Review the radiology reports to assess whether the reports indicated urgent referral according to local policy.
Obtain a list of the last months reports coded "Urgent" according to local policy, if the RMS allows. Cross check with the Hospital Patient Information System to ensure patients have been referred appropriately. If the RMS system does not allow for an “Urgent” report to be coded in your institution the audit should be carried out prospectively.
Copies of all reports with a suspected diagnosis of malignancy should be kept for 1-4 weeks (according to local workload).
The Hospital Patient Information System should be interrogated to ensure all patients have had appropriate onward referral.
-
Suggested number
3 months consecutive referrals
Ensure the policy for communication of urgent reports is robust.
Make sure all referring clinicians are aware of the agreed referral pathways for site specific cancers.
Repeat the audit at 6 months.
IT facilities and clerical time to pull the necessary lists.
Clinical time to deal with all the safety net queries.
Clerical time for performing the HIS check. This person needs appropriate clinical experience and skills to understand information presented in the Hospital Information system. Time will also be needed for GP cases as direct contact will in the main be the only way of checking the correct actions and referral have occurred.
Allow eight hours per year for scrutinising records and preparing Formal Annual Report.
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
All Trusts were given a deadline of 28th of April 2007 to agree an action plan in response to NPSA Notice 16 with an implementation deadline of 28th of February 2008. An audit to monitor compliance would be timely in terms of Clinical Governance for the Trust.
Dr Sue Barter 01/02/2008
19 February 2008