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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 where the care of a patient was inappropriate because of a lack of follow up of a diagnostic report. A patient who was treated for chronic myeloid leukemia had a CT scan that showed a large lung mass that was suspicious of a cancer as well as fluid on the lung. The patient was referred to the thoracic Disease Site Group to determine if radiation therapy would be an option but the patient declined the appointment because of their deteriorating condition. The patient was enrolled in the palliative care program and was transferred to a home dedicated to end of life patients. After 14 months in the home the patient was improving. The physician at the home asked for a review of the CT scan. This showed that the mass was not a cancer but rather a pleural effusion (collapse of the lung due to accumulation of fluid in the lung). Contributing factors were identified: -An aggressive treatment time line can result in gaps in care processes. In this case, the CT scan, referral, admission to hospital, declining referral and enrollment in palliative care all occurred within 24-48 hours. The patient was not followed by the cancer agency after being enrolled in palliative care. -Although it is standard practice for the referring physician to be made aware when a patient declines the referral, it was not done in this case. A standard process for all referring clerks to document referral cancellations is needed. A recommendation to prevent similar incidents is provided.



Missed Amended Pathology Report