May 2, 2008

Review of Pathology Results Underway

Physicians and patients being contacted

Diagnostic Services of Manitoba and the Winnipeg Regional Health Authority announced today that a review is being conducted on recent pathology results from a DSM pathologist due to concerns that were identified through DSM's internal quality assurance process. A review of 35 selected complex cases uncovered diagnostic errors which resulted in amended reports for seven of the cases and a review of 107 randomly selected general cases from February 2008 resulted in two amended reports. These reports do not necessarily mean a change in treatment is required.

The referring physicians and their patients are being contacted. The physicians will discuss changes in pathology diagnosis with their patients and inform them of any need to alter treatment. If there is a need for any patient to receive additional treatment as a result in a change in diagnosis, those patients will be treated on an expedited basis.

In addition to the review, DSM and WRHA have initiated a Critical Incident Review in order to determine what steps can be taken to improve processes and prevent a reoccurrence. As well, the College of Physicians and Surgeons of Manitoba has been notified of the issue and will be updated as the review progresses.

Making a diagnosis from a surgical tissue sample (such as a biopsy specimen) in not always straightforward. Different pathologists may have slightly different interpretations. As such, it is premature to conclude that there is a significant problem associated with this particular pathologist.

An external pathologist is reviewing all complex cases related to this pathologist from the last year and the review will be completed in the next few weeks. Any pathology reports that are changed will be immediately communicated to the referring physician who will then contact their patients. In the meantime, the pathologist in question will remain on leave from the system.

"The main lesson from Sinclair and Thomas Reports was that the principles of patient safety cannot be served unless there is disclosure to patients when errors occur," WRHA President and CEO Dr. Brian Postl said.

Dr. Jim Dalton, CEO of DSM said the issue is being made public out of an abundance of caution. "The issue of patient safety has guided DSM's, and the Region's decision-making. Together, we are working with CancerCare Manitoba and other providers to ensure all appropriate measures are taken," Dr. Dalton said.

WRHA has established a dedicated phone line, 788-8004, to address questions and concerns from the public. Further updates will be provided as more information becomes available.

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