That was the conclusion of Dr. Doug Cochrane – Provincial Patient Safety and Quality Officer and chair of the BC Patient Safety & Quality Council – who was asked to lead a two-part investigation into the quality of diagnostic imagining in the province after a series of events in four health authorities called that quality into question. The review was initiated back in February, and as a result, nearly 8,000 studies were reviewed by independent and qualified radiologists to look for clinically-significant discrepancies from the original interpretations, including about 100 CT scans performed at the Dawson Creek and District Hospital over a two-month period last year by a radiologist identified in the review who had temporarily provided services to the local hospital.
Radiographs, ultrasound and mammography interpretations were reviewed and all found to be within accepted ranges for discrepancies. However, computed tomography (CT) studies, which triggered the initial concern, showed the most clinically-significant discrepancies with a range of one to 17 per cent depending on the area and individual.
“The principal issue falls in the realm of CT scanning,” said Cochrane. “Delays in treatment occurred, changes in treatment were required, repeat testing was necessary, and additional or repeated procedures or interventions occurred because of these errors. For most patients there was no direct impact on their health, as primary care providers and others recognized the errors and acted to mitigate them so that patients were not directly affected. Unfortunately, the health of a small number of patients were directly affected by these errors because they received incorrect treatment based on the initial interpretations, or the treatment they needed was delayed because of the time required for the review and may have been less affected than anticipated.”
When asked by reporters, he said no patients died as a direct result of those misinterpretations, but the changes or delays to treatment resulting no doubt had adverse effects on those individuals – about a dozen patients, he said – including possibly death. Later, Health Minister Michael de Jong added he was aware of three patients who cases were reviewed that had since passed away, though he said it’s not clear if there was a direct causality in those cases.
Cochrane said the reason for the misinterpretations varied – for example, a radiologist at Powell River General Hospital was found to be practicing radiology and providing services using modalities (computed tomography and obstetrical ultrasound imaging) that were beyond the scope defined by his license to practice medicine in British Columbia. In all cases, Cochrane provides a detailed summary and chronology of events in his report, which has been attached below. However, he said there were underlying factors contributing to each case.
“These factors included the failure of the credentials review process, privileging, and medical review processes of the college and the health authorities,” he said. “In most situations, there was no credible monitoring program in place that would have detected these deficiencies and addressed them at an earlier stage.”
He recommends that the ministry, the College and the health authorities work together on a standardized approach to licencing, credential review and privileging for appointment and reappointment of radiologists, including sharing information on the competencies and skills of individual practitioners in an open and transparent way where appropriate. He also recommends a peer review and performance management system should be created to support physicians in their practices, adding he is encouraged by the pilot program being developed for peer review of diagnostic imaging on Vancouver Island.
Cochrane added communication needs to be improved between healthcare providers and patients, their families and the general public when adverse events occur.
“Patients and families clearly voiced dissatisfaction with the processes that were used to communicate with them as individuals and as members of the public. To address this issue, we recommend that a protocol or guideline be developed for use in British Columbia if such events occur, if they ever occur, in the future.”
“These events have had a huge impact on patients, families and the communities in which they occurred," he concluded. "Faith and trust in the health system has been shaken by these events. It’s imperative that the system that rebuilds trust and answers the issues identified in this investigation to prevent these and similar events from recurring.”
Minister de Jong said his government has an action plan to address the gaps identified in Cochrane’s plan, which has also been attached below.
“It is clear to me from Dr. Cochrane’s report that there is need to imbed those safeguards across the system in a systemic way to ensure the highest quality of patient care and give British Columbians the confidence they want and deserve in our healthcare system,” said the minister.
He also expressed an apology on behalf of his government to those patients and their families affected by the misinterpretations of diagnostic imaging studies.