Sask. region to re-interpret 8,000 CT
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
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
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
Posted January 27, 2011