Saskatoon Reviews Medical Imaging System Errors
Saskatoon Health Region has found that a system error resulted in a number of patient medical imaging reports not being sent to physicians’ offices over the past decade.
The error came to the Region’s attention on May 6, 2009 when a physician contacted the medical imaging department to find out why he did not receive a patient’s report. The Region has taken steps to correct the situation.
After reviewing 2.2 million reports that were sent out over a ten year period it was found that 1380 faxed reports did not reach the physicians’ offices. Patient reports are entered into the Radiology Information System (RIS) and faxed to the patient’s physician. In each of the 1380 cases, the reports were still available through the RIS.
“The safety of our patients is first and foremost and we apologize that this situation has occurred,” said David Poulin, Vice President, Medical Affairs. “As soon as this issue was brought to our attention we began a thorough investigation. That investigation is continuing and will include, over the next week, the work of a clinical review panel to review each case and determine if patient safety and quality of care were compromised as a result of a patient’s diagnostic test result not reaching a physician member of the care team.”
Over the next few days the Region will begin telephoning those patients and their physicians affected by this situation. The Region will continue to work closely with those individuals to determine if care was compromised.
“Working with our patients and clinical teams, we expect to find that in most cases care was likely not compromised. However, the Region has a responsibility to communicate any adverse event where the patient could unintentionally be harmed because of the care or service provided by the Region. This is not only the right thing to do; it is also the ethical and legal thing to do. It is an opportunity to learn from our errors, reduce the potential for harm to our patients and enhance the quality of care for everyone,” said Poulin.