{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,21]],"date-time":"2025-10-21T15:15:33Z","timestamp":1761059733146},"reference-count":18,"publisher":"Wiley","issue":"4","license":[{"start":{"date-parts":[[2014,5,20]],"date-time":"2014-05-20T00:00:00Z","timestamp":1400544000000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/onlinelibrary.wiley.com\/termsAndConditions#vor"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Evaluation Clinical Practice"],"published-print":{"date-parts":[[2014,8]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:sec><jats:title>Rationale, aims and objectives<\/jats:title><jats:p>This study aimed to apply the \u2018systems approach\u2019 to patient safety in order to identify causes for delays and errors in lung cancer diagnoses following an abnormal chest radiograph.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>In the first part of this study, the systems approach to patient safety was comprehensively reviewed by three radiologists and seven patient safety experts.\u2009In the second part of this study, a retrospective review was performed of all patients referred to the lung cancer multidisciplinary team (<jats:styled-content style=\"fixed-case\">MDT<\/jats:styled-content>) meeting over a 1\u2010year period. All abnormal chest radiograph reports were examined and a root\u2013cause analysis performed of cases where errors and delays in diagnoses were deemed to have occurred.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>A total of 124 cases were reviewed, of which 36 (29%) patients had an abnormal preceding chest radiograph prior to <jats:styled-content style=\"fixed-case\">MDT<\/jats:styled-content> referral. In six cases, serious errors from delay and lack of follow\u2010up were identified. These are analysed and discussed in detail in this article. Application of the systems approach to each case identified poor communication and lack of clinical action as prime causes.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>Both reporting radiologists and referring clinicians have a responsibility to ensure appropriate action following an abnormal chest radiograph. The main error lies in communication between the referring clinicians and the radiologists. Direct electronic communication is potentially a more robust method to overcome this.<\/jats:p><\/jats:sec>","DOI":"10.1111\/jep.12178","type":"journal-article","created":{"date-parts":[[2014,5,20]],"date-time":"2014-05-20T06:44:41Z","timestamp":1400568281000},"page":"453-459","source":"Crossref","is-referenced-by-count":3,"title":["Delays and errors in abnormal chest radiograph follow\u2010up: a systems approach to promoting patient safety in radiology"],"prefix":"10.1111","volume":"20","author":[{"given":"Basrull Najmi","family":"Bhaludin","sequence":"first","affiliation":[{"name":"Department of Radiology St. George's Healthcare NHS Trust  London UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Susan Cheng","family":"Shelmerdine","sequence":"additional","affiliation":[{"name":"Department of Radiology St. George's Healthcare NHS Trust  London UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sonal","family":"Arora","sequence":"additional","affiliation":[{"name":"Clinical Safety Research Unit, Department of Bio\u2010Surgery and Surgical Technology Imperial College London  London UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Taiwo","family":"Senbanjo","sequence":"additional","affiliation":[{"name":"Department of Radiology Epsom and St. Helier University Hospitals NHS Trust  Carshalton UK"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Arum","family":"Parthipun","sequence":"additional","affiliation":[{"name":"Department of Radiology Epsom and St. Helier University Hospitals NHS Trust  Carshalton UK"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"311","published-online":{"date-parts":[[2014,5,20]]},"reference":[{"key":"e_1_2_7_2_1","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.322.7285.517"},{"key":"e_1_2_7_3_1","doi-asserted-by":"publisher","DOI":"10.2214\/ajr.167.3.8751657"},{"key":"e_1_2_7_4_1","doi-asserted-by":"publisher","DOI":"10.1259\/bjr.72.856.10474490"},{"key":"e_1_2_7_5_1","doi-asserted-by":"publisher","DOI":"10.1136\/qshc.2004.009910"},{"key":"e_1_2_7_6_1","doi-asserted-by":"publisher","DOI":"10.1007\/s00464-002-8509-3"},{"key":"e_1_2_7_7_1","doi-asserted-by":"publisher","DOI":"10.1097\/01.sla.0000118753.22830.41"},{"key":"e_1_2_7_8_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijsu.2009.12.007"},{"key":"e_1_2_7_9_1","doi-asserted-by":"publisher","DOI":"10.4329\/wjr.v2.i10.377"},{"key":"e_1_2_7_10_1","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.316.7138.1154"},{"key":"e_1_2_7_11_1","volume-title":"Lung Cancer Claims Study","author":"Physician Insurers Association of America","year":"2005"},{"key":"e_1_2_7_12_1","doi-asserted-by":"publisher","DOI":"10.1136\/pmj.78.917.158"},{"key":"e_1_2_7_13_1","unstructured":"The Royal College of Radiologists (UK)(2002).Framework for risk management."},{"key":"e_1_2_7_14_1","unstructured":"The Royal College of Radiologists (UK)(2008).Standards for the communication of critical urgent and unexpected significant radiological findings."},{"key":"e_1_2_7_15_1","unstructured":"National Institute for Health and Clinical Excellence(2011).The diagnosis and treatment of lung cancer (update). 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