Misread medical imaging tests resulted in delayed treatment or other medical issues for a dozen British Columbia patients, including three people who have died since problems with their scans were detected, B.C.’s Health Minister says.
A review investigating four radiologists found 12 patients whose care and health had been significantly affected by diagnostic issues such as, for example, delayed chemotherapy. Three of those people have died, Michael de Jong said Tuesday.
“I can’t give you, nor will I, a definitive statement today on the degree to which misreading of images contributed to that – but those are the numbers,” he said.
Health authorities reviewed thousands of scans after authorities learned of problems with credentials and test readings involving four radiologists.
On Tuesday, the province promised an overhaul of the medical imaging sector and Mr. de Jong apologized to those affected, including families of people who didn’t get timely treatment and others who lost sleep wondering if their scans had been misread.
“All of that [anxiety]occurred at a time when they should have been able to solely focus on getting well,” Mr. de Jong said at a Vancouver press conference after the release of a report Tuesday into medical imaging. “To all of those patients and their families, I, we, are very, very sorry.”
Mr. de Jong said B.C. will implement all of the recommendations included in the report, the second part of a two-stage review into medical imaging.
The government commissioned the review – written by Doug Cochrane, chair of the B.C. Patient Safety and Quality Council – in February, after learning of problems dating as far back as October that involved radiologist credentials and practices.
The problems included a radiologist at Powell River who was providing services for which he lacked credentials. That radiologist has since resigned.
Health authorities reread thousands of scans to check for discrepancies. All patients requiring follow-up are being contacted by health officials.
Compensation for those affected will likely be discussed, Mr. de Jong said.
Of the four radiologists discussed in the report, three are no longer practising in B.C., and one that is, is practising within his approved scope of practice, Mr. de Jong said.
Asked if anyone had died as a result of misread scans, Dr. Cochrane said no one died as a direct result of imaging misinterpretation, but that treatment was changed.
Janet Baird, a Powell River resident whose father, John Moser, died of cancer in January, believes he suffered unnecessarily after a scan last August did not detect any problems.
By the time he was admitted into the hospital in December, the cancer had spread and Mr. Moser died in January.
“He literally collapsed before he was finally diagnosed with cancer,” Ms. Baird said on Tuesday from her home in Powell River.”
The medical director of Powell River General Hospital, Pavel Makarewicz, resigned from that position.
Dr. Makarewicz has said he wants to focus on his surgery practice and step back from administrative and policy work, said Patrick O’Connor, vice-president of medicine, quality and safety, Vancouver Coastal Health, to which the Powell River hospital belongs. Dr. O’Connor said he received the resignation letter from the Powell River physician on Monday.
Dr. Makarewicz was integrally involved with the review and his resignation is not linked to its findings, Dr. O’Connor said. “It would be nice to think that if you took one person out, this would all go away,” Dr. O’Connor said. “But in fact, we are humans, and if the system isn’t working – that mistake would be repeated.”
The report calls for comprehensive peer review and clinical audit review for all specialties in the province, not just radiology.
“We have pockets of excellent quality review work going on; mandating that spread across all localities and all physicians is a big body of work, but we’re quite committed to it,” Dr. O’Connor said.
Of the cases reviewed in Vancouver Coastal Health, one scan resulted in an unnecessary procedure, a colonoscopy, Dr. O’Connor said. In other cases, patients received a delayed diagnosis or treatment.
The province said it would implement a “timely peer review system” across B.C. and establish a common electronic registry accessible to the College of Physicians and Surgeons of B.C., health authorities and the Ministry of Health to track licensing, credentials and privileges.
B.C.’s Ministry of Health commissioned a review of medical scans in the province in February, after problems emerged with test readings by four radiologists who practised primarily in Powell River, Comox and the Fraser Valley.
The second phase of the report, released Tuesday, focused on gaps in the system that allowed the problems to develop. The report’s 35 recommendations include:
– a provincewide peer review system for diagnostic imaging
– establish an image library for teaching purposes of difficult interpretations and common errors
– that Comox-based St. Joseph’s General Hospital – a denominational facility that operates under the Diocese of Victoria – participate in a provincewide review process into how radiologists are granted credentials and hospital privileges
– a progress report on implementing the recommendations in September, 2012Report Typo/Error