Radiology review shows no new cases of patient harm

A health authority in central Newfoundland said Thursday that a review of radiology reports used to help diagnose disease has uncovered no additional instances of patient harm, beyond two cases that had already been identified.

Central Health said that of 2,827 reports that had been examined in a wide-ranging review that started last month, all but 15 were correct.

Moreover, Central Health chief executive officer Karen McGrath said the review did not identify any patients who encountered harm beyond two identified in November, when the review was launched.

"When we started this review we didn't know what we would find," Central Health CEO Karen McGrath told CBC News Thursday.

"When we started reviewing numbers of images — nearly 300 images — we quite frankly anticipated that we may find some harm. We have not found any harm beyond the harm that I identified in my original release."

Central Health launched the review after it discovered that two visiting radiologists had written reports based on old — rather than most recent — medical tests.

Asked if the two visiting doctors were to blame, McGrath said they were not.  "We believe that there were a number of system issues which aligned to make this occurrence happen."

Central Health said the other errors involved a variety of factors, including human error.

The report pointed also to "system issues" that include inadequate orientation for visiting physicians when they arrive, as well as gaps in training for existing staff and changes in how diagnostic images are archived.

"We call it in health care the holes in the Swiss cheese lineup," McGrath said.  "There are a number of things that occur, that make an incident occur, when there are system failures from a number of perspectives."

The authority had already described some of the errors in November, during a public update on the review.

For instance, it disclosed that a radiologist had filed a report noting two normal kidneys in a patient, even though the image showed only one. In another, a radiologist had missed a case of pneumonia that was later caught, prompting treatment.