The Importance Of Flagging Abnormal X-ray Findings Not Detected In A&E
In anonymised case notes, experts analysed how a patient’s finger injury worsened due to communication and procedural errors within a UK hospital.
Initially, the person concerned attended an NHS accident and emergency department after hurting an index finger. On the first visit, duty medical staff took an X-ray and diagnosed an injury to the soft tissue.
Next, they strapped the finger, advising the patient that the bandage should remain in place for three to five days. Then, before discharging the patient from the hospital, medics prescribed analgesics to relieve pain and discomfort from the swelling.
Undiagnosed fracture
However, a few days afterwards, the patient was still experiencing continued swelling and pain in the damaged first finger of the left hand. On returning to the same hospital, triage nurses noted the original X-ray but did not report any findings. Instead, they referred the case to the virtual fracture clinic.
Three days later, on reviewing the X-ray, clinicians diagnosed a fracture accompanied by swelling of the surrounding tissue. Notably, clinic staff did not telephone or write to the patient to relay the diagnosis, provide care instructions or arrange another appointment. According to investigation notes, the hospital took no further action at the time.
A month later, the patient returned to A&E triage, reporting continued discomfort and a limited range of movement in the finger. Straight away, staff requested a second X-ray which revealed further damage in comparison to the first X-ray. As a result, surgical intervention was necessary to address the aggravated injury.
After the operation, the stiffness and a reduced range of finger movement persisted.
Learning points
On review, it was clear that staff had not diagnosed the trauma correctly. Proper identification of the injury occurred only after several days.
However, when staff eventually diagnosed the fracture, they did not notify the A&E department. Furthermore, no one contacted the patient to pass on the diagnosis and inform them of the recommended treatment.
Significantly, it was not until almost two months later that the correct information emerged. Even then, the details came to light only when the patient went back to A&E. By that time, the displaced fracture needed an operation to remedy the damage.
Recommendations
To improve patient safety and care standards by preventing the recurrence of such incidents, medical safety and clinical risk analysts recommended that:
- Emergency department clinicians ought to receive regular training in interpreting x-ray results.
- Healthcare management would do well to introduce key performance indicators to monitor turnaround times and X-ray reporting.
- Duty radiologists ought to review X-rays of injuries.
- Reviewing radiologists should also flag up abnormal findings to A&E staff so that injuries do not escape detection.
If the abnormal result had come to light without delay during or shortly after initial treatment, the patient would have been aware of the fracture. Crucially, clinical staff could have treated the injury correctly without such an untimely delay.
On a linked note, management should improve communication channels so that timely, practical information reaches patients whenever necessary in injury cases. Doing so will minimise deterioration by adjusting behaviour and ensuring that patients return as soon as possible for appropriate treatment if required.
New medical findings – such as those discovered on review – require prompt referral to the appropriate medical professional(s). Had the hospital acted sooner in the above case, the displacement of the fracture would not have occurred.
Summary
Regrettably, a surgical operation became necessary in the end because of delays in reporting X-ray results and failure to communicate the revised diagnosis. The haphazard circumstances and delay in delivering correct treatment led to long-term problems in the affected finger. To secure better outcomes in future, therefore, it remains essential to flag up abnormal X-rays and inform patients immediately of any changes in diagnoses.