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Single or Multiple Incident: Single
Date: 2/1/2019 12:00:00 AM
Country: Canada
Organization: Manitoba Health
This patient safety learning advisory describes a patient safety incident of delayed treatment and complications related to a missed diagnostic finding. A patient had a cancer removed from their cheek. Five months later, a follow up CT scan showed a thickening of the cheek. The surgeon ordered a PET scan to rule out any further disease. The PET scan showed four findings. Only one finding was noted in the patient's chart: "asymmetric metabolic activity in the region of left base of tongue/tonsil". The fourth finding listed on the report “A concerning finding of significant metabolic activity in the uterine cavity” was not addressed. Two months later, the patient was experiencing post-menopausal bleeding. A biopsy was performed. The pathology showed invasive adenocarcinoma of the cervix/endometrium. The patient was admitted to hospital due to various complications relating to the disease. According to the surgical team who ordered the PET scan, an assumption was made that the patient was seeing a different physician for hematuria and therefore their physician would follow up on the results of the PET scan. Typically this finding on the PET scan would be addressed by sending a referral to the gynecologic -oncology group or a follow up ultrasound would be performed. In this case, neither intervention was completed. A recommendation to prevent similar incidents is provided.


Rules / Policies / Procedures
  1. At the facility where this originated, a field will be added to all image test requisitions to carbon copy the family physician on the results.

All Results from Diagnostic Imaging Not Addressed