WRHA makes changes after needless double mastectomy

Winnipeg health officials have formally apologized to a woman who underwent an unnecessary double mastectomy last year and say they are introducing significant procedural changes to help prevent the same kind of situation from happening again.

Last week the CBC I-Team reported that in 2014, a patient had undergone a double mastectomy only to learn afterwards that there was no cancer present in her breast tissue. At the time, the province wouldn't go into detail about what had happened or what was being done to address it.

• Manitoba patient has double mastectomy, later learns did not have cancer

The Winnipeg Regional Health Authority has since acknowledged that the patient was in its care.

Dr. Brock Wright, the WRHA's senior vice-president of clinical services and chief medical officer, sat down with CBC News late Tuesday to outline the changes. He began with a public apology to the patient.

"On behalf of all of the care providers who looked after this particular patient," Wright said, "we're very sorry for what happened."

To prevent such a case from happening again, the health authority is changing how it handles surgical breast cancer cases. Those changes paint a fuller picture of what may have gone wrong in the case.

"The recommendation that will have the most profound impact," Wright said, "are [sic] changes to the patient safety checklist."

Typically the surgical team goes through a three-part checklist before each stage of the operation. In this case, it turns out it was missing one crucial step that it has now put into practice.

• ON MOBILE? View the WRHA's surgical safety checklist here.

"What's never been included on the surgical safety checklist is a question about was the actual pathology report reviewed," Wright said. "We've now added that to the surgical safety checklist for all patients."

He added, "Without getting into the specifics, I'm confident that a change like this would have prevented a case like this from happening again."

In addition to ensuring the surgeon has reviewed the finalized pathology report before any incisions are made, the WRHA has other changes still in the works.

Among them are finding a better way to flag changes and adding amended reports to the patient file.

"What we learned is that often the amended, corrected information is actually put at the back of the incorrect report," Wright said. "We're looking at changing that so that the change in the report is more obvious."

Another change is ensuring all final pathology reports are readily electronically available to the entire medical team.

Currently, pathology reports are not available through the WRHA's electronic medical record system, eChart. It's an electronic health information sharing system that allows health-care providers to access important patient information.

"The advantage of having those reports available electronically is that any physician involved in that patient's care could go through eChart and access that chart immediately and not have to rely on the paper system," Wright said, adding that the authority hopes to have pathology reports available on eChart by 2016.

So what about the patient at the heart of the changes?

Wright said the health authority apologized to the patient as soon as it discovered the mistake. He said the authority offered her support and medical services to mitigate the error.

She has asked for her right to privacy to be respected.

Questions still remain as to whether there will be a formal learning summary of the case. That's a detailed description and analysis of what went wrong along the patient's journey, often used to help health-care providers learn from mistakes made in the system.

But Wright said patients entering the system should feel confident the problem has been addressed.

"This is a very rare event," he said. "The changes that we made in the critical incident review will prevent this from happening again and we have a very excellent safety record for patients in the breast health centre."