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June 26, 2008

Pathology Review Update

The review of the work of a specific pathologist is now complete.

The review, prompted by concerns identified through Diagnotsic Services Manitoba's internal quality assurance processes, was conducted to determine if significant problems existed with the work of this pathologist. Following an initial internal audit of 35 select complex cases, DSM ordered an external review, which included a cross section of cases from the month of February 2008 as well as a sampling of complex cases from the past year. A total of 822 cases were examined by the external reviewer.

Of the 822 cases, two complex cases were identified as having errors in diagnosis that resulted in clinical impact for patients.

In one case, a cancerous tissue sample from a colon was reported as benign. The patient's physician has determined that further investigation is needed to determine if additional treatment is required. As there was only a short amount of time between the original and amended diagnoses, there is no impact on the patient's prognosis.

In a second case, a patient had a partial thyroidectomy. The tissue sample was originally read by the pathologist as benign but has now been determined to be cancerous. As a result further surgery may be required. The patient's physician has advised that as this is a very slow growing tumour, the delay in diagnosis and treatment should not impact the patient's prognosis.

An additional 40 cases were found to have pathological errors or discrepancies, however they did not result in any clinical impact.

DSM and the Winnipeg Regional Health Authority (WRHA) consider any impact to patients to be a very serious matter. The two impacted patients have already been notified and additional care is being provided on an expedited basis.

DSM, the WRHA and the pathologist in question regret the impact to these and all other patients affected and apologize for any anxiety this process has caused them.

Pathology is an interpretive science. At the intermediate stages of the progression of distinctly normal cells to cancer cells, it can sometimes be very difficult to unequivocally determine a diagnosis. As such, there is a rate of expected error. The review found the rate of errors of this pathologist to be within the published average.

The external reviewer found that overall the pathologist showed good work practices. As the errors were not found to be of an identifiable pattern, the external reviewer had no suggestions for improvements to DSM's quality systems.

However, for personal reasons, this pathologist has informed DSM and the WRHA of his decision to retire. A dedicated and respected practitioner, he has given many years of service to healthcare in Winnipeg and has led an accomplished career.

DSM was created by the government of Manitoba to develop a provincial diagnostic system, which would be positioned to meet rising quality standards. Since inception DSM has been proactively working toward systematic improvements to enhance services and patient safety through quality improvements in all diagnostic disciplines.

Review Summary:

  • The scope of the review included a total of 822 cases: 314 cases from the month of February 2008 and 508 complex cases handled over the past year.

  • 2 cases were found to have errors which had patient impact.

  • 40 cases were found to have errors or discrepancies in pathology, but which did not lead to patient impact.

  • The patients and/or physicians involved in all of the cases with errors have been contacted.

As the WRHA Inquiry Line has not received any calls for over a week, the line is no longer taking messages. Should patients have concerns they are encouraged to contact their physician.

  • A total of 333 calls were received.

  • The pathologist in question was involved in 60 of the 333 cases. In 56 of the cases the pathology was determined to have been reviewed and read correctly.

  • In the remaining 4 cases, the pathologist was only one of several involved in reviewing multiple samples from those cases. While the review of those cases continues, because of a number of tests and a number of different pathologists involved, it is not expected that any of these patients would have been clinically impacted by his work.

For more information contact:

Krista Sinaisky
Diagnostic Services of Manitoba
Phone: (204) 926-7194

Heidi Graham
Winnipeg Regional Health Authority
Phone: (204) 926-7178

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