Key Points

Please take a moment to review these points, reflect on their significance and consider how they apply to your own experiences.

Tick to confirm (optional):

• Quarantine mislabelled images immediately and preserve original files for investigation.
• Create a dated, signed addendum describing the error and maintain a full audit trail when relinking files.
• Notify relevant clinical recipients and review any decisions influenced by the erroneous image; contact affected patients if required.
• Perform root‑cause analysis (identity checks, device/workflow failures, staffing) and implement controls such as two‑identifier checks and daily reconciliation.
• Record corrective actions and training in the governance log for audit and accountability.
• Document absence of legacy paper notes in the record and base clinical decisions on current findings, avoiding assumptions.
• Initiate retrieval, scanning and indexed linkage of missing historical notes with validation checks.
• Develop and follow a downtime/transition policy defining responsibilities, timescales, validation and recheck procedures to prevent recurrence.