NL reviews years of mammo studies for possible errors
September 7, 2022
ST. JOHN’S, NL – Mammography images from more than 16,000 Newfoundland and Labrador patients are under review after health officials discovered a problem with the way employees were examining diagnostic images. Newfoundland and Labrador’s four regional health authorities will review thousands of diagnostic images stretching back to 2018, after confirming patients across the province have been screened for breast cancer on inadequate monitors.
Eastern Health’s audit to date has identified 3,800 exams since 2018 that “will require further review,” said Kenneth Baird (pictured), interim president and CEO, at a news conference Wednesday.
Labrador-Grenfell Health will send 2,530 images for a closer inspection, while Western Health is looking at 7,554 tests, for nearly 14,000 new tests in question.
That’s in addition to about 3,000 tests from Central Health already under review. That audit began last week after the health authority noticed it had been using out-of-date monitors to look at its mammography images.
Baird said the health authorities may need to look outside the province for radiologists to pore over more than 16,000 images and ensure diagnostic imaging can proceed normally.
Central Health said Monday it retained a radiologist to examine affected diagnostic images. That radiologist has reviewed images from 837 patients as of Aug. 26, and found four “potential discrepancies or differing interpretations.”
The potential errors may have occurred because employees had been reading the images on substandard monitors for the last three years, using three-megapixel monitors, which don’t meet the standards for viewing and interpreting mammograms. As of 2018, guidelines recommend a higher-quality, five-megapixel monitor to examine mammography images.
Dr. Angela Pickles, clinical chief of medical imaging at Eastern Health, told CBC News that it’s difficult to say whether lower-quality monitors are to blame for the four potential errors found to date. “We’re only human, and as we interpret any imaging … there’s always going to be slight differences in opinion,” she said. “In my experience it would be highly unlikely to be solely due to the monitors. It’s likely to do with … human error.”
The loss of the lower-quality workstations, Baird said, shouldn’t affect current procedures. “There is no implication here for the quality of mammography service,” he told reporters. “This is very limited in scope, to the monitor that has been used to review the mammography image. It’s not going to impact on … availability.”
The audit comes a decade after a judicial inquiry, known as the Cameron inquiry, found that Eastern Health failed patients with shoddy laboratory work and “practically non-existent” quality controls, after it gave nearly 400 breast cancer patients incorrect hormone receptor test results.
“We have concerns about what went wrong. Where was the oversight? Where were the checks and balances?” asked interim PC Leader David Brazil later Wednesday, speaking to reporters at the House of Assembly.
“Did people follow anything that we learned from the Cameron inquiry? Why was it that more people weren’t engaged earlier in this whole process, and who’s responsible for what’s happened?
“Somebody has not done their job here. Somebody needs to be accountable for not following the process that had already been identified.”