When the patient sought care for swollen legs, an X-ray examination showed a change in one of the lungs and a CT scan was ordered. The plan was that the X-ray result would be followed up at the patient's next doctor's visit.
Missed X-ray results
But the locum doctor who then received the patient missed that an X-ray result had arrived and the patient never received any follow-up on the suspected cancer. It wasn't until a year and a half later, when a new CT scan was done for other reasons, that the change was noticed and the patient was referred to the lung clinic.
Region Dalarna has reported the incident to Lex Maria and a new routine, where a permanently employed doctor regularly checks that all X-ray results have been handled, has been introduced, according to a press release.