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Patient safety

Pathology errors lead to exam review

EDMONTON – Serious mistakes by one Alberta pathologist has resulted in a high-priority re-examination of more than 100 prostate exams and more than 1,500 other tests that he read while working at Edmonton's Royal Alexandra Hospital.

After reviewing 126 of the 159 prostate biopsies in question, 15 patients who had been told they didn’t have cancer have now been told they do have cancer cells in their prostates. The review also showed 14 reports had underestimated the aggressiveness of the cancer, 46 had minor discrepancies and 51 showed no discrepancies.

The medical crisis brought an apology from the head of Alberta Health Services. “First of all, I want to sincerely apologize for any distress and concern that this incident will have, or has had on patients and families in Alberta,” said AHS president and CEO Chris Eagle (pictured).

“These discrepancies are significant and the change in reporting may impact the future treatment of some patients.”

Eagle said the review of the test results was launched after a urologist operating on a patient at the hospital noticed that there was a significant difference between what he was seeing during surgery and what the pathologist’s report had stated.

The pathologist who wrote the reports on 1,700 exams conducted between July and September has since retired, Eagle said, adding his name would not be made public. “We work in an environment where we don’t blame or shame the concept of a justice and trust culture,” the AHS head said.

While there is no indication of discrepancies in other tests, AHS is in the process of reviewing 1,568 additional non-prostate specimens that were interpreted by the pathologist during that period. They will be reviewed on a priority basis.

Bill Taylor, a prostate cancer survivor, told CTV news he was shocked by the misreading of the tests. “That would be quite upsetting,” he said. “If you were told your results were understated and you didn’t have any problems, it would be pretty horrifying to find out a year later or some months later you might have a problem.”

The Edmonton review by the Health Quality Council follows a similar situation in Calgary where tests conducted at Rockyview General Hospital were re-examined last month. Alberta Liberal leader Raj Sherman said the provincial government should look into the faulty test results.

“That’s twice now,” he said. “These are not isolated incidents. Is this happening elsewhere? The public needs answers on this.”

While there is no evidence of discrepancies, AHS will be reviewing all 1,568 specimens read by the pathologist at the RAH. It will take some time to complete all 1,568 re-reads, however, priority will be assigned to all cancer-related specimens or for those individuals who have surgical procedures booked. The most urgent cases will be re-read first. Lung biopsy reviews, for example, will be prioritized over gall bladder or vasectomy reviews.

Albertans should know that there are safeguards in place to ensure the accuracy of their biopsies. In fact, AHS has set a target of 10% for reviewing a random sample of all biopsies. The Royal Alexandra Hospital review rate for the first six months of 2011 is 9.58%. Although there is no established review rate in Canada, Alberta’s standard is higher than a College of American Pathologists study which found an aggregate review rate of 8.2% in the United States.


Posted December 15, 2011

 

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