The Importance of Flagging Abnormal X-ray Findings that are Not Detected in the Emergency Department

A Case Example

The patient attended A&E after injuring their left index finger. An X-ray was performed, yet not reported, and the patient was diagnosed with a soft tissue injury. The patient was discharged with finger strapping for three to five days and pain relief. Several days later, they re-attended A&E with ongoing symptoms and was referred to the Virtual Fracture Clinic. The initial X-ray was noted yet still not reported. A further three days later, the X-ray was reported as a fracture of the left index finger with soft tissue swelling. No further action was taken, and the patient was not informed of the report.

Over a month later, the patient attended A&E with ongoing pain and reduced range of movement. A X-ray was taken which showed further damage compared with first X-ray. The patient underwent surgery and continues to suffer from stiffness and reduced movement of the index finger. The main learning points from this review stem from the following events:

  • The fracture was not diagnosed on the day that the X-ray was taken. There was a delay of several days before the fracture was correctly identified.
  • Once the X-ray was reported on, there was no action taken to notify the Emergency Department.
  • There was no clear attempt made to contact the patient to inform them of the diagnosis.
  • It was not until the patient reattended A&E nearly two months after the initial injury that they were informed of the presence of a fracture. By this point the fracture had displaced and the patient required surgery.

Recommendations to Prevent Incident Recurrence and Improve Patient Safety

TMLEP’s recommendations to reduce recurrence and enhance patient safety are as follows:

  • Provide further education for Emergency Department clinicians in interpreting X-rays. Although, it is still recommended that a radiologist also reviews the X-ray. It is recommended that healthcare providers introduce key performance indicators to monitor report turnaround times.
  • Employ a mechanism by which abnormal X-ray findings, that are not detected in the first X-ray by A&E clinicians, are flagged to the Emergency Department by radiologists following X-ray reports. In this case, had the abnormal findings been picked up, the patient would have been notified of the findings and reviewed further in the fracture clinic.
  • Instigate a process to promptly and effectively communicate any changes in diagnosis to the patient. This is essential, especially in fracture cases, so that the patient can adjust their behaviour to minimise any damage and return to the healthcare provider for alternative treatment.
  • Ensure that new findings are flagged so that appropriate referral can be made promptly. This would help to ensure that further action is taken where necessary and would help avoid further deterioration. In this case, had the patient been reviewed in the fracture clinic and sent for a repeat X-ray the displacement of the fracture would have been know and appropriately treated.

Conclusions

In summary, this case surrounds the delay in reporting an X-ray and informing the patient of the presence of the fracture. These delays led to the patient requiring surgery due to the displacement of the fracture. This additionally has led to permanent stiffness of the finger.

TMLEP would like to highlight the importance of flagging abnormal X-ray findings and promptly informing the patient of any change in their diagnosis so that prompt referral can be made, and the patient can adjust their behaviour accordingly to minimize any further damage.

Important Note

This article is intended to raise awareness to clinical risk issues in an effort to reduce incidence recurrence and improve patient safety. This is not intended to be relied upon as advice. Facts have been altered to ensure this case is non-identifiable, albeit clinical learning points remain applicable.