Thursday, November 2, 2017

Radiology inquiry releases findings

Discrepancies from imagery results
out of Mills Memorial sparked
the provincial review
The provincial investigation into performance incidents in four provincial health authorities, focused on the work of a Terrace based radiologist has delivered its final report, a document which includes an overview of the situation that led to the situation out of Terrace of wrong results, as well as twenty recommendations for the College of Physicians and Health authorities to implement.

The report was compiled in the months following a review of work at Mills Memorial Hospital in Terrace, which had resulted in discrepancies found in a number of scans conducted by Dr. Claude Vezina at the Terrace hospital.

Background to the first notice of those discrepancies and the follow review can be found below:

May 2017 -- Concerns from Mills Memorial Hospital Radiology results review expands to other health organizations
April 2017 -- Mills Memorial radiology results review now complete
February 2017 -- Concerns over Radiology results at Mills Memorial Hospital spark Northern Health review

Prior to his employment at Mills Memorial, the radiologist had also worked at Interior Health, Island Health and the Vancouver Coastal Health Authority, his time of employment with British Columbia health authorities spanned the period of 2011 to 2017 when he was placed on indefinite leave at the Terrace facility.

Among the notes from the report by Doctor Martin Wale is the need for assurance for the public that the whole system is working as it should, a theme which the report addresses by noting three conditions that should be met.

All physicians must participate in improvement activities

There must be effective professional mechanisms to support those in difficulty

There must be clear escalation mechanisms for use when a problem is serious or when professional mechanisms are not working. These will trigger investigation, and performance management if necessary.

When it comes to confidence about physician quality, the closing  paragraph of the introduction to the report provides the focus that should be in place to reassure the public about the services that they receive

All clinicians have a duty under the Health Professions Act to report concerns about clinical care, but this is ineffective for marginal performance concerns. This situation could have been detected earlier if a series of small signals had been assembled into a picture of poor performance, instead of coming to light through a significant patient safety incident, ultimately affecting thousands of British Columbians. Better information sharing is the key to early detection. 

Finally, this review makes observations about the need for coherent policy in this difficult area, and makes recommendations about how the findings may be addressed.

The review highlighted how the situation could have been detected sooner had key information been available for reference checking and had been shared among Health authorities. The report takes note how concerns about privacy and working relationships limited the ability to seek information, even when it impacts patient safety.

The process of tracking past employment experience, as well as performance review while in the position also was flagged as a problem area that contributed to the incidents of the last six years.

To address those concerns and other issues the report delivered twenty recommendations, listed on pages 9-11 of the 52 page report, those findings are listed below: (click to enlarge)





The full report can be reviewed here.

Northern Health has to this point not offered up any background to their response on the report findings.

Dr. Vezina, is still listed by Northern Health as being on voluntary leave from the Terrace facility.

Some of the media notes related to the report can be found below:

Radiologist with questionable skills was able to skirt scrutiny, B.C. investigator finds
Review of radiologist's medical images for IH finds 6% misinterpreted
B.C. radiologist's questionable work missed due to poor communication, privacy concerns, report finds
Radiology review finds 10 per cent discrepancy
Radiologist was able to skirt scrutiny: report


For more notes related to Northern Health see our archive page here.

Cross posted from the North Coast Review

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