A comprehensive review system might have detected ongoing problems in the work of a radiologist based at Mills Memorial Hospital which resulted in the reinterpretation of approximately 8,400 images, states a report commissioned by the provincial health ministry.
Instead it was a non-radiologist disagreeing with the interpretation of a CT image of one of his patients that sparked the wholesale reinterpretation of the images from nearly 5,300 patients from the region, the report stated.
“This situation could have been detected earlier if a series of small signals had been assembled into a picture of poor performance, instead of coming to light through a significant patient safety incident, ultimately affecting thousands of British Columbians,” wrote review author Dr. Martin Wale from a group called the B.C. Medical Quality Initiative, which works to improve health care in the province.
The radiologist, Dr. Claude Vezina, began work at Mills Memorial Hospital in a fulltime permanent position October 3, 2016, but was placed on voluntary leave on January 27, 2017, once the alarm was raised about discrepancies in the CT, x-ray and ultrasound images.
A discrepancy rate of 10 per cent was found by radiologists at Vancouver General Hospital, double the accepted norm.
The Northern Health Authority (NHA) then sent letters to approximately 700 patients and their doctors regarding follow-ups with health authorities, noting that a discrepancy didn’t mean treatments would have been changed or a patient’s ongoing health was affected.
“Those notifications were done – on a case-by-case basis, essentially in real time – about any clinically significant discrepancies found, so that physicians could determine if a discrepancy resulted in any change in diagnosis, or treatment, and follow up accordingly,” said NHA’s Eryn Collins.
Vezina had close to 20 years’ experience as a radiologist in northern Ontario, rising to a senior administrative position before leaving.
He spent periods of time as a temporary or locum specialist in other parts of B.C. before arriving in Terrace as a full time radiologist last fall.
A review of images from those periods was also conducted with no problems found by the Vancouver Coastal Health Authority, a 15 per cent discrepancy rate by the Island Health Authority and a 6 per cent discrepancy rate by the Interior Health Authority.
Wale’s examination of the Terrace situation included looking back at earlier problems found with radiology services on Vancouver Island in 2010.
This resulted in a series of recommendations that were never fully implemented, Wale indicated.
In that situation concerns arose over inadequate training or physicians working outside of their licensing limits compared, to Vezina who was working within his training and licensing.
If Wale found a system of fully checking radiologists’ on-going work was lacking, he also undertook a broader review of how all physicians and specialists are recruited, references are obtained, their credentials are confirmed and how their ongoing performance was evaluated.
Although Wale indicated recruitment and credential checking had improved as a result of the recommendations from the Vancouver Island problems of 2010, there were still gaps.
”The [Terrace] incident highlights multiple failures to effectively share information, between physician leaders themselves, and between physician leaders and regulators – both medical affairs departments in their role as the physician-regulatory part of the health authority and also the College of Physicians and Surgeons of B.C. and regulatory colleges in other jurisdictions,” Wale wrote.
In regards to Vezina, Wale found there was lack of documentation surrounding his work as a locum in other places in B.C. and why, in some instances, he was not accepted into a full time position.
And while there is an overall checking of references, Wale noted, “many medical leaders are reluctant to be too honest when writing references, in case the reference is seen by the subject and regarded as unhelpful or even defamatory.
“They may also be keen to be rid of the individual, so would not wish to undermine a chance to do so by giving anything other than a positive reference”.
“However, as well as references being inaccurately positive, so too they may occasionally be unfair or unjustly harsh (e.g. where there is personal animosity).”
Specific to radiology, the experience from the Vancouver Island situation in 2010 resulted in creating the Radiology Quality Improvement System (RQIS) meant to be instructional for radiologists by having their work reviewed by other radiologists for quality assurance and quality improvement.
Vezina was never part of that either as a locum in other parts of B.C. or when he signed on to work at Mills, Wale indicated.
And by the time Vezina was to have been brought into RQIS, in early Februrary of this year, he was already on leave.
“Locums and new appointees need to be specifically identified to the RQIS team, and a process needs to be in place to ensure this happens,” Wale wrote.
He stressed that radiologists need to buy into RQIS by having “good processes in place whereby peers manage and provide support to those making low impact errors or who are marginally underperforming. This would include additional sampling frequency”.
“The primary aim of the system is to improve patient care quality,” Wale wrote.
Wales did acknowledge that there is at times pressure and urgency to fill vacancies in smaller health centres. And he did recommend that working conditions of radiologists be reviewed so as to reduce situations where they may be interrupted while at their work.
Wale’s recommendations to improve recruiting and credential checking methods and ongoing performance reviews, released October 26, are now resulting in what the provincial government is calling an ‘action plan’.
Collins said the NHA accepts the review and is looking forward “to working with the Ministry of Health to implement the recommendations”.
“This provincial review provides an important set of recommendations that include improvements that can be made around those processes and others – and Northern Health will be working with the Ministry of Health and other health authorities, to implement the recommendations directed to health authorities,” she said.
Vezina’s status, added Collins, “is unchanged at the moment and the radiologist remains on voluntary leave”.
Although the NHA required physicians who received letters about scan discrepancies to confirm they had contacted patients, Collins said those physicians aren’t “required to share the details of diagnosis or treatment with the health authority”.
“Imaging is only one piece of a diagnosis, so it is possible patients would have had appropriate interventions based on the results of other tests or investigations that were completed, aside from a particular imaging exam,” she added.