1/9/11

Over 4,000 unreported x-rays at Tullamore hospital

A NATIONAL Radiology Survey has revealed that over 4,000 x-rays went unreported at the Midlands Regional Hospital, Tullamore between 2009 and 2010. 2,905 index fracture and orthopaedic studies x-rays were unreported in 2009 and 1,129 in 2010.
Dr Maurice Hayes was commissioned by the HSE to investigate the accumulation of unreported x-rays in Tallaght Hospital and concerned with establishing if this was an issue in other HSE funded hospitals, a National Radiology Survey was undertaken. Work on the survey, to identify any radiology backlogs and to report on their resolution, was carried out between March 10 and November 4 last.

Out of a total annual workload of more than 2.5 million examinations each year across all hospitals, the total number of investigations returned as unreported by a radiologist was 33,914. This represented less than 0.5% of all activity over the period (2008 – present).

Remedial actions were taken in all hospitals that reported non-compliance and there were no instances of adverse event (patient harm) reported to the HSE as a consequence of backlogs. This is in keeping with the initial assessment that the practices in place, while informal, were in practice appropriately identifying certain investigations as low risk and appropriate for reviewing by clinicians other than radiologists.

In one site an adverse event was reported relating to an instance of delayed cancer diagnosis due to an unreported x-ray. This had been noted prior to the national survey. This case has been investigated and fully communicated to the patient.

In a statement, the HSE said it is implementing the recommendations of Dr Maurice Hayes' report, adding, "These measures will drive improvements in the quality of service and will help to prevent the recurrence of further backlogs of unreported radiology.

"The lessons learned from the Hayes report and the national audit will contribute to improvements across the hospital system. The roll out of the National Integrated Medical Information System (NIMIS) will further strengthening radiology services, quality and processes within our health system."

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