New report echoes problems identified in March
Low morale, workload issues, dysfunctional work relationships among staff and lack of expertise in complex areas have been identified once again in a review of Eastern Health laboratories.
© Gary Hebbard/The Telegram
Vicki Kaminski, president and CEO of Eastern Health, speaks to the media Thursday, to release the Review of Laboratories of Eastern Health by University Health Network.
Eastern Health president and CEO Vickie Kaminski said the authority has already been working hard at consolidation, which was recommended earlier this year.
“We have a number of services consolidated now at the Health Sciences Centre,” she said. However, cytology which is still located at the Miller Centre hasn’t been consolidated. “It does need to move,” Kaminski said.
UHN was initially contracted by Eastern Health in March following the discovery of cyclosporine testing errors that are estimated to have potentially affected 212 patients.
Cyclosporine is an immunosuppressant drug, widely used in transplant patients, which has to be regularly monitored through blood tests. The errors produced inaccurate low cyclosporine blood levels.
UHN says the laboratory acted appropriately by ceasing in-house testing, initiating external testing and informing physicians immediately when the problem was identified.
The problem related to a new “Premier” mass spectrometer installed in 2009. UHN concluded that the equipment performance was not the reason for the errors. But the “Premier” spectrometer and older “Ultima” model required different methods for testing and sensitivity to certain metabolites using the new equipment produced false readings.
The UHN team said data for both systems was recorded on the same chart, without differentiation of the spectrometer used. They’ve recommended immediate use of separate charts for each system to identify trends and enable troubleshooting.
UHN has also recommended the hiring of a certified clinical biochemist with strength in mass spectrometry and bi-weekly or monthly exchange of a limited number of samples with another lab for verification of results until confidence is restored in the local lab.
Kaminski said the errors were picked up in February when dual tests were run on the old and new machines and samples compared. “In that particular part of the report, when we discussed it today, what was said that stuck in my mind was ‘validate, check, validate, check, check, check, check,’ so keep on checking and err on the side of caution,” she said.
Dr. Pat Parfrey, a nephrologist and research chief with Eastern Health, has been reviewing all the cyclosporine cases and the outcomes for patients affected.
“He’s almost finished that report and will be handing it over to us in the next few weeks,” Kaminski said.
In the meantime, she said, standard operating practices and separate documentation for testing have already been put in place.
The 55-page UHN report contains numerous recommendations relating to staff, improvements in procedures and laboratory work spaces.
It says among medical staff, a workload distribution system was inappropriately being used to determine individual workload as opposed to departmental workload for staffing adjustments.
There’s some commonality across lab systems across Canada,” says Brad Davis, executive director of University Health Network’s (UHN) laboratory medicine program
The report notes that medical staff have recently been moved from St. Clare’s to the Health Sciences Centre and this single site model has decreased the sense that the two groups have separate work but just happen to be in the same department.
The report, however, says the separation of medical staff into MUN-appointed professors and hospital-appointed staff is “divisive and offensive.”
For the group to function as a team, the UHN says they must all hold responsibility for academic activities. It’s recommending the allocation of 20 per cent protected time for academic activities for all members of the department, with access to MUN libraries and other resources for pathologists to keep current with medical literature.
The current surgical pathology lab space at the Health Sciences Centre has been deemed by the UHN as unsuitable, with a ventilation system that’s insufficient and gross bench workspaces configured in areas that are too small or in high traffic locations.
Over the next couple of days, Kaminski said Eastern Health will be sharing this report with all its lab staff, divisional chiefs and employees. The administration also plans to review the report in detail and establish an action plan and cost analysis to implement the recommendations.
The bottom line, Kaminski said, is about ensuring patient safety. “However, it would be unreasonable and disingenuous for me to say to the people we serve that we will be 100 per cent error free. No lab can provide that assurance. We can only work towards that goal.”
Kaminski said Eastern Health has a “strong, well qualified team” of laboratory professionals. “It is our responsibility as an organization to ensure that they have the proper leadership, the appropriate infrastructure, use best practices and have access to whatever other tools they require to be able to carry out their work to ensure that our patients receive quality and safe care.”
Kaminski said Eastern Health is also currently preparing for an accreditation of its laboratories, which is being done under the guidance of the Department of Health and Community Services.
Michael O’Keefe, chairman of Eastern Health’s board of trustees, said it’s the board’s responsibility to have policy directives in place to help the health authority achieve optimum safety.
He said despite the recent errors, Eastern Health provides care to hundreds of thousands of patients and there are many more interactions that go right than wrong.