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34,000 x-rays unreported nationally
[Posted: Tue 21/12/2010 by Niall Hunter, Editor www.irishhealth.com]
Nearly 34,000 x-rays in hospitals around the country had not been reported on by a radiologists over the past two years, according to a new HSE survey.
The HSE has stressed that "no clinical incidents of patient harm", such as delayed or misdiagnosis, emerged in its audit.
However, the HSE says in one site an adverse event was reported relating to a delayed cancer diagnosis due to an unreported x-ray. The HSE says this had been noted prior to its national survey - the case has been investigated and fully communicated to the patient, according to the report.
The HSE said that as this case was kniown about and was already been dealt with and discussed with the patient, it was not included in the survey. It said it "deeply regrets this incident".
It has not yet been revealed in which hospital this delayed diagnosis incident took place
It said the backlog has now been cleared across the system nationally. "All x-rays have been appropriately reported on and hospitals have put in place measures to prevent the recurrence of backlogs."
The HSE said that while the national survey did not uncover any adverse events, it acknowledged there was understandable anxiety among patients that this could have occurred.
It said it regretted this and apologised to all affected persons.
The HSE has revealed than when it began to survey hospitals on their unreported x-ray backlog in May of this year, a total of 15 reported that they were not in compliance with guidelines which outlined in which cases x-rays needed to be reported on by radiologists.
The hospitals with backlogs under this heading were - Beaumont; Connolly; Kerry; Kilcreene Orthopaedic; St Luke's, Kilkenny; Portlaoise; Crumlin; Tullamore; Loughlinstown; Waterford Regional; Lourdes, Drogheda;Cork University;Temple Street; the Rotunda and Our Lady's Navan.
The report says remedial actions were subsequently taken in these hospitals. These actions were to address the backlog of unreported tests and ensure that all outstanding examinations were now reported on by a radiologist.
However, the HSE's report reveals that a small number of x-rays went missing in some hospitals and even after extensive searching, were deemed "irretrievable."
The audit says a process was put in place for dealing with missing x-rays, which included consideration on whether a repeat examination was necessary following a review of the clinical scenario.
The single biggest unreported test backlog the audit found in a particular category in a hospital was 3,605 chest x-rays at Cork University Hospital (CUH) in 2008.
CUH had one of the the biggest number of unreported x-rays in the survey over the two years, with 6,079. The highest number was at Waterford Regional (8,314) while Beaumont in Dublin had 5,626 in total between 2008 and 2010.
The survey found the number of unreported x-rays rose at Beaumont from 983 to 3,144 between 2008 and 2010.
The audit was carried out following the unreported x-ray scandal which broke at Tallaght Hospital earlier this year, when it was revealed that 57,000 x-rays going back a number of years went unreported by radiologists at that hospital.
The audit of all hospitals went back to 2008. The health executive said the total number of unreported x-rays represented less than 0.5% within radiology services nationwide. It says around 2.5 million x-ray tests are carried out every year in hospitals nationally.
The HSE said the fact that no adverse incidents were reported demonstrates that while reporting practices were in some cases informal, hospitals were identifying low-risk x-rays which were appropriately reviewed by doctors other than radiologists.
The health executive said it had now established a quality and clinical care directorate which was focused on improving quality and safety in radiology.
The programme determines the circumstances where it is acceptable that x-ray investigations would not be reviewed by radiologists and instances where a radiologist's report was a requirement, it said.
"These resulted in national guidelines for radiology reporting which were completed in association with the Faculty of Radiologists earlier this year," the HSE said.
All hospitals have assured the HSE that they are in compliance with the new guidelines.
The HSE said it was implementing the recommendations of the recent Hayes report on the Tallaght scandal.
It said a quality assurance programme in radiology which will reduce the possibility of x-ray errors and adverse events, will begin implementation next year.
In addition, a new "filmless" x-ray infrastructure across hospitals will significantly reduce the likelihood of lost x-rays. according to the HSE.
Read the full report here
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