title: Delay in diagnosis of cancer as a patient safety issue - a root cause analysis based on a representative case report.
abstract: BACKGROUND
  It is well known in the literature that imaging has almost no value for diagnosis of superficial bladder cancer. However, wide gap exists between knowledge on diagnosis of bladder cancer and actual clinical practice.
  
  
  METHODS
  Delay in diagnosis of bladder cancer in a male person with tetraplegia occurred because of reliance on negative flexible cystoscopy and single biopsy, negative ultrasound examination of urinary bladder, and computerised tomography of pelvis. Difficulties in scheduling cystoscopy also contributed to a delay of nearly ten months between the onset of haematuria and establishing a histological diagnosis of vesical malignancy in this patient. The time interval between transurethral resection and cystectomy was 42 days. This delay was mainly due to scheduling of surgery.
  
  
  CONCLUSIONS
  We learn from this case that doctors should be aware of the limitations of negative flexible cystoscopy and single biopsy, cytology of urine, ultrasound examination of urinary bladder, and computed tomography of pelvis for diagnosis of bladder cancer in spinal cord injury patients. Random bladder biopsies must be considered under general anaesthesia when there is high suspicion of bladder cancer. Spinal cord injury patients with lesions above T-6 may develop autonomic dysreflexia; therefore, one should be extremely well prepared to prevent or manage autonomic dysreflexia when performing cystoscopy and bladder biopsy. Spinal cord injury patients, who pass blood in urine, should be accorded top priority in scheduling of investigations and surgical procedures.
authors.affiliation: Regional Spinal Injuries Centre, Town Lane, Southport, Merseyside PR8 6PN, UK. subramanian.vaidyanathan@nhs.net.
authors.forename: Subramanian
authors.initials: S
authors.lastname: Vaidyanathan
authors.forename: Bakul M
authors.initials: BM
authors.lastname: Soni
authors.forename: Gurpreet
authors.initials: G
authors.lastname: Singh
authors.forename: Peter L
authors.initials: PL
authors.lastname: Hughes
authors.forename: Paul
authors.initials: P
authors.lastname: Mansour
authors.forename: Tun
authors.initials: T
authors.lastname: Oo