Review complete, no new cases of patient harm

Terri Saunders
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Gander - Fifteen medical reports provided to physicians over the past year were based on incorrect diagnostic images, officials with Central Health have determined.

Following a six-week investigation, officials announced last Thursday they reviewed 2,827 reports, 2,470 of which were based on correct images.

Investigators determined 342 reports were based on correct images, but additional information needed to be added to the patient files.

In total, the investigation reviewed reports involving 2,194 patients. The reports were produced by two visiting radiologists during the periods of October through December 2010, May and June 2011 and July through September 2011.

Officials confirmed they had previously been made aware of two cases of patient harm related to the incorrect reports, but had identified no additional cases through the course of the investigation.

"While I am very pleased to report that the appropriate physicians have determined that there is no further patient harm, we certainly acknowledge that this may not have been the case," said Central Health CEO Karen McGrath.

"The investigation has been an extremely valuable experience that has allowed us to gain a comprehensive understanding of the factors that contributed to what happened and how it happened."

McGrath said investigating radiologists added information to 342 reports that were based on the correct image.

"When one radiologist reviews the work of another radiologist, they will add additional information to the report," she said. "They may suggest a followup occur or they may suggest that a repeat exam needs to be done, that kind of thing."

McGrath said when Central Health began the review, health officials had no idea of the extent of the harm.

"We had two cases that we reported on when we commenced this review and, quite frankly, at that time I was concerned that we may have found others."

McGrath said doctors who received letters from Central Health indicating a report had been based on an incorrect image were encouraged to contact health officials if there were concerns about patient harm.

"We have advised all attending physicians," she said.

"They were given a date by which they were to report to us. That date has now passed, and they have reported no additional harm, other than the two instances that I indicated when I originally commenced the review."

Officials said there were a number of factors that contributed to an incorrect image being read, including human error, the need for enhanced orientation and training, the need to enhance a culture of quality and patient safety, and technology.

The report includes several recommendations, including a mandatory orientation process for new and locum radiologists, the implementation of voice recognition software for reporting of diagnostic images, and enhancing system functions to discriminate between historical and current images to reduce the likelihood of human error.

"Now that we have determined the direction we need to take to achieve our goals, we will begin the process of implementing the recommendations," McGrath said.

"I have confidence in the recommendations of this report, and we are eager to move forward with implementation to continue to improve patient safety and quality at Central Health."

 

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  • David
    December 24, 2011 - 12:50

    Well I guess your definition of "patient harm" must not include the very real, insidious and systematic destruction of any small bit of remaining confidence and trust any of us might still have in our health care 'system'. I would say that getting a positive test result in this province is not nearly as reassuring a diagnosis as it is anywhere else, and intolerably inconclusive given the enormous public resources we dedicate to producing it.