Download appendix 1 1Plain Films Findings audit v2 [docx / 55KB]

Radiology – Unreported Plain Films – Audit/summary of findings
Introduction:
There is a large volume of unreported “plain films examinations”, within the Trust, which
increases month on month. There is insufficient radiological capacity to view and report on
these images, raising concerns for patient safety and care. This is logged on the Trusts risk
register. Reporting one months images retrospectively was done to evaluate the possible
consequences of this situation. The results of this are detailed within this paper.
Background:
This is a historical problem, which has more recently increased due to ever growing
pressures and demands upon the Radiology services. The result is that many plain film
examinations never have a formal report issued by a clinician trained for this (radiologist or
reporting radiographer).
Many in patient, out patient and A&E images remain in an “unreported state”, relying
solely on the hope that any pathology has been picked up by the medical teams who
requested and have hopefully reviewed the images and that any pathology seen has been
noted and the patient managed accordingly.
The typical number of unreported plain films is around 4,200 per month and there is a huge
backlog of many 1,000’s of unreported images on the PACS system going back many years.
Radiology were asked by the Trusts ERMC, (Executive Risk Management Committee) to send
away one months unreported plain films to understand what issues were raised so the
Trust could advise on action to address this and if there should be a future plan for these
images to be formally reviewed. It was suggested to take one months unreported plain films
from the last 3 months, for this exercise.
The images taken in June 2013 were selected at random and the volume of unreported films
that month was 4,160. If reported off site this would have cost around £4 per image
(£16,640), however some staff volunteered to do this in their own time, at £2 per image,
significantly reducing the cost and also the subsequent support costs in arranging for offsite
viewing.
The breakdown of this work was:
Chest X-rays
Abdomen X-rays
Cervical Spine X-rays
Other Skeletal X-rays
Total
2837
536
28
759
4160
The Mix of patient type was:
In Patients
Out Patients
A&E
45%
14%
41%
Methodology:
All films were viewed and reported by experienced Consultant Radiologists, who did the film
reporting out of contracted hours and were asked to flag within the report if there was:




Expected pathology demonstrated on x-ray
Pathology found but not that clinically significant, but should have been brought to
the attention of a Clinician
Pathology identified on x-ray which is considered highly significant and we are
unsure whether it had been acted upon
If there was no flag then this would indicate it was normal (or nothing of
significance)
The reports were then extracted from the CRIS system. 421 were flagged as being abnormal
(10%) and the findings on those flagged are summarised below.
Summary of Findings:
Chest
Infection
179
Pleural effusion/
Pulmonary
Oedema/Heart failure
Pneumothorax
Mass/nodule
Enlarged Heart
Widened mediastinum
? Thoracic Aortic
Aneurysm
Metastases
Enlarged hilum
Pleural Plagues
Incarcerated hiatus
hernia
Tube Position (NG or
other)
44
Obstruction
Constipation/Faecal
loading/
20
2
4
16
18
2
3
Of these, in 10 patients the infection had
become worse
Of these in 2 patients the Pleural effusion had
become worse
1 patient has still not had any follow up
1
2
2
1
12
In 1 patient the tube was lying in the right main
bronchus – it had been relocated soon after
Abdomen
Perforation
Paralytic Ileus
Gallstones
? tumour
Inflammation
Renal Tract calculi
1
1
1
1
2
15
Fracture
Metastases
Degenerative/OA
Pagets
Bone Infection
Abscess
Joint Effusion
? Avascular Necrosis
19
3
23
1
4
1
1
2
Known tumour
1 has not been followed up, 1 other was new
Bone
Likely unknown
In at least 46 cases, follow up imaging, alternative imaging or clinical correlation was recommended.
Checking on the CRIS system it appears that this was not always done.
Some serious pathology was found during this exercise which raises concern. These are listed below
with a brief summary of the issue/s.
Pathology found during the reporting of these studies, which raise concern
 Large Pnemothorax –
Chest Xray in A&E. Patient admitted, however the chest drain was not put in until hrs on the
following day, , which raises the question, was this seen at the time of admission? The patient had
an ultrasound and plain KUB on in which he was unable to hold his breath due to being tachpnoeic.
It suggests that his US was to investigate his right sided pain. If this scenario is correct then it raises
delay in diagnosing an urgent medical condition and unnecessary other investigations.
 Missed lung Nodule –
Likely Cancer in a young person who was an in patient admitted with cough and LRTI. She has
since had a CT scan and is under the care of the respiratory team. She is now awaiting biopsy.
Raise the issue of serious missed pathology.
 Large Pulmonary Mass Large pulmonary mass on right. Patient came back in to A&E 15 days later and the mass was seen
then. Raises the issue of unnecessary re admission to A&E as well as missed pathology, delay in
diagnosis.

Nasogastric tube above diaphragm –NG tube above diaphragm on. No evidence on CRIS it
was re sited. Repeat CXR on for aspiration pneumonia.
 NG tube in Right Main bronchus –
NG in right main bronchus on Xray. Repeat CXR on CRIS at suggests delay in repositioning.

Suspicious lung nodule Further investigation required and advised. No follow has been up
noted on CRIS.
 ?? FB in Chest
No follow up done.
 NG tube above diaphragm
On CRIS does not appear to have been repositioned uuntil
 ? Thoracic AA on CXR Follow up advised to exclude TAA but not done

# pubic rami –No follow up noted on CRIS
 Wedge # T12- L1
Lateral film recommended. Requested by GP in
 Missed lung nodule –
Has since had a CT requested by the GP in light of the finding. Has now been identified as
normal.
 ET tube in right main bronchus –
Also lung collapsed – am not aware if this was withdrawn into the trachea.


Missed lung nodule –
CT arranged since by GP but patient has declined.
Abnormal densities in lung CT recommended but this has not been followed up
 ? lung opacity –
CT recommended to rule out significant pathology. No follow up appears to have been done
Conclusion:
Plain film imaging that does not benefit from the expertise of trained staff to interpret the
image and provide a formal report, will mean that Pathology and serious pathology will be
missed. This will be detrimental to the care of the patient, place the Trust at risk and may
also lead to unnecessary other imaging or re admission.
The data for June was chosen at random. There are, as demonstrated above, some
significant issues that are raised for the care and well being of our patients and the long
term consequences of this.