Quebec X-ray record debacle revisited

Hospital staff at Pierre-Le-Gardeur are still trying to figure out how 14,000 patient X-ray reports went missing over the past year.

A “computer glitch” is being blamed for the mishap, but the human element

is being examined in light of possible law suits.

“Knowing the truth is going to be very difficult,” said Normand Laberge, chief executive officer of the Canadian Association of Radiologists. “Everybody’s going to want to protect themselves.””

At the newly built hospital in Lachenaie, near Montreal, results of mammograms, MRIs and CT scans are stored digitally, printed and mailed to physicians. But between January and December 2004, 14,000 reports were never printed out or sent to physicians. “In terms of real results, 800 to 900 were positive,” said Laberge. In one case, there was a six-month delay in a cancer diagnosis, he said, and a law suit will likely occur from that.

The hospital tried to downplay the incident, saying that 85 per cent of the reports were negative and didn’t need to be sent to physicians. “You’re dealing with life here – an 85 per cent passing grade doesn’t cut it,” said Laberge. “If the tests were not important, then why the hell were they issued?”

A spokesperson for Pierre-Le-Gardeur, Frederique Laurier, said the hospital is dealing with its IT issues and that it is to soon to comment further on the incident.

It was a patient that wouldn’t take no for an answer that finally set alarm bells off at the hospital, after she demanded to see the results of her examination, first from her physician, then the hospital. An investigation revealed that her report was not the only one that had disappeared into cyberspace.

“I think everybody will be shifting the blame,” said Laberge. And that blame might shift to the IT industry. But he said this is taking the easy way out. “You can’t blame the IT company for the end result (of the report) not reaching the patient.” Other issues being raised are: hospital staff didn’t double-check the computer’s work, physicians didn’t follow up with the hospital and ask for results that didn’t arrive automatically, and patients didn’t follow up with their physicians. “IT does not erase people, does not reduce workload,” he said. “It’s not the magic bullet to everything.”

Losing data in cyberspace is an everyday event, he said. And hospitals know they lose patient records: in a manual system, the rate of loss is three to four per cent, while a digital system is one to two per cent. In a digital environment, that loss is temporary and the data can be retrieved from the system. Problems will occur, but they can be caught early on through human intervention.

By having a computer around, some people assume they don’t have to check anything, said Laberge. “This is exactly what happened at Pierre-Le-Gardeur,” he said. “Three other hospitals (in Canada) have the same system but not the same problem.”

The University Health Network, for example, went digital in 2000 and now all of its X-rays (with the exception of its archives) are stored on a computer. The UHN comprises three Toronto hospitals: Toronto General, Princess Margaret and Toronto Western. “There’s a queue for every report that’s signed off,” said John Adziovsky, the UHN’s PACS architect. The report is automatically faxed to the physician, he said, but someone at the hospital continuously monitors the queue, providing a human element to the system. If a report is particularly important, a physician can call the hospital and have the report printed out and sent immediately. The hospital also has backup for all of its systems in two different buildings spaced one km apart.

Canadian hospitals use RIS, or radiology information systems, from different vendors and have different human intervention levels. “But [IT vendors] follow the same principles,” said Adziovsky, and common IT backup and disaster recovery should catch glitches, no matter what product a hospital is using.

“What we’ve seen is a lesson of the potential domino effect of trusting up the line,” said Laberge. “The hospital goofed, but someone else down the line also goofed.” Mistakes are going to happen, he said, but hospitals need to be prepared to deal with those mistakes and other system failures, like power outages.

In Canada, 35 million radiology tests (including X-rays) are conducted every year. Eighty per cent of Canadian hospitals will be moving to electronic patient records over the next few years – and this kind of problem could accelerate if proper controls aren’t put in place, he said. These controls include comparing input to output, and ensuring that positive reports are actually sent to physicians. He’s certain about one thing though: “I can bet every single day someone (at Pierre-Le-Gardeur) is doing the reconciliation.”

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Vawn Himmelsbach
Vawn Himmelsbach
Is a Toronto-based journalist and regular contributor to IT World Canada's publications.

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