box10.gif (1299 bytes)








Sask. region to re-interpret 8,000 CT scans

SWIFT CURRENT, Sask. – Cypress Health Region announced that it will have all CT scans re-interpreted that were originally read by a radiologist during the period of October 1,2004 to December 31, 2007. The complete review is being launched because an unexpectedly high rate of error was found in a first group of exams read by the radiologist that were submitted for re-interpretation.

As part of its ongoing quality improvement process and emphasis on patient safety, the Cypress Health Region forwarded a total of 7,662 computed tomography (CT) examinations in 2010 to be re-interpreted by an external radiologist group. The review project, which covered two time frames, was considered necessary following concerns initiating from a routine quality assurance audit report that was provided by the College of Physicians and Surgeons, as contracted by Saskatchewan Health.

Given the overall results of the radiologist group's findings regarding the 7,662 scans first examined, the Cypress Health Region and the Ministry of Health have determined that a more comprehensive review of CT scan examinations is required. Therefore, a complete review of all CT scan examinations originally interpreted by one radiologist during the period of October 1, 2004 to December 31, 2007 will be immediately initiated.

That amounts to approximately 8,000 CT scan examinations from the 39-month timeframe. The review will begin with the most recent examinations and will ensure that any required follow-up action is addressed in conjunction with the patients’ family physicians.

A number of the CT scans from this timeframe have already been re-interpreted as part of the earlier random sample completed, and therefore these examinations will not be subject to another re-interpretation. As well, those patients who had a duplicate CT scan of the same body part at a later date would not require a re-interpretation of their original CT scan.

Cypress Health Interim CEO Beth Vachon (pictured above) acknowledged the efforts of the administrative and diagnostic imaging staff, who have collectively dedicated nearly 3,600 hours to the initial review.

For the original review time frame of January 2008 to May 2010, a total of 7,213 patient examinations were re-interpreted. A clinically significant variance in interpretation was noted in 864 of the examinations. This is a 12.0% variance rate. For the time frame of January 2005 to November 2007, a random sample of 449 examinations was drawn to be re-interpreted. For this period, a clinically significant variance was seen in 59 of the examinations that were re-interpreted. This is a 13.1% variance rate.

A clinically significant variance in interpretation is considered one which has a potential to affect patient care. In light of this, to ensure patient safety processes were in place, Cypress Health staff has already contacted nearly all (approximately 95%) of the patients whose examinations were re-interpreted, with the exception of those with undeliverable mailing addresses.

Continued attempts are being made to contact these individuals, as well as to complete the provision of information to the remaining 5% of patients whose CT examinations have been reviewed. Patients’ family physicians are also receiving the second interpretation of the CT scan and when they deem it appropriate, it is being reviewed with the patient.

Posted January 27, 2011