Public awaits findings from board of inquiry empaneled by the Alberta Health System

Once more, a province in Canada is dealing with public disclosure of unacceptable rates of errors in anatomic pathology testing services. This time it is the healthcare system of Alberta. Since November, the public has learned about two separate cases of individual pathologists who were determined to have misdiagnosed cancer cases.

But pathology errors turned out to be only part of this story. Public concern in Alberta about the quality of diagnostics services was further heightened by another round of newspaper stories later in December. This time, the news was about the discovery of imaging errors made by a radiologist working in one of Alberta’s hospitals.

In response to these three separate episodes of diagnostic failures by two pathologists and a radiologist, the Alberta Health Service (AHS) announced a board of inquiry.

First Disclosure of Anatomic Pathology Errors in November

This series of events started with the disclosure, in November 2011, that there were misdiagnoses because of errors committed by a pathologist working at 642-bed Rockyview General Hospital in Calgary. At least 31 prostate biopsy diagnoses handled by this pathologist were to be reviewed.

The second discovery of diagnostic errors came on December 3, 2011. That is the day that provincial health service executives acknowledged to the public that errors had been detected in the cancer cases diagnosed by a pathologist working at the 658-bed Royal Alexander Hospital in Edmonton.

It was reported that, of 159 prostate biopsy slides examined by this pathologist in the preceding summer, retests of 126 slides determined that 51 slides had no discrepancies from that pathologist’s original reports. However, there were 49 “minor” discrepancies and 29 “substantial” discrepancies.

Among these 29 cases, there were 14 cases where the pathologist underestimated the aggressiveness of the patient’s cancer. For the other 15 cases, “the pathologist’s initial reading missed small numbers of cancer cells.” As many as 1,700 diagnoses made by this pathologist are to be “retested” during this review.

Days after these revelations, news surfaced that a third episode of diagnostic errors had been discovered in Alberta. This time, it involved a radiologist and not a pathologist. At a site in the little town of Drumheller—population 8,000—misdiagnoses by a radiologist triggered a review of 250 X-rays, ultrasounds, and MRIs.

It was determined that there were 34 “interpretation errors” attributable to this radiologist. But, in covering these developments, a story published by Toronto’s Globe and Mail  newspaper, reporter Dawn Walton wrote “The findings thus far are so alarming that officials have further expanded the review of the radiologist’s work to reassess about 1,300 CT scans performed over the past six months. That review will take several weeks.”

In response to three separate episodes of diagnostic errors involving two pathologists and a radiologist, Alberta’s Health and Wellness Minister Fred Horne conducted a press conference on December 29 and announced that a board of inquiry would be empaneled to assess the cause of errors in pathology and radiology, then make recommendations. Horne assured the public that, in his view, patient care in the province was not at risk. (photo copyright Calgary Sun.)

In all three episodes, the Alberta Health Service contacted patients affected by the misdiagnoses. During his press conference on December 29, 2011, to announce the formation of a board of inquiry, Health and Wellness Minister Fred Horne stated that “This examination is a proactive measure that will provide me and all Albertans with the necessary assurance that the system-wide checks and balances are in place and operating as they should be.

“This is not about blaming the people that deliver the care,” he said. “This is about answering some very fundamental questions about checks and balances in our health-care system… I have no reason to believe that patient care is at risk.”

For pathologists and clinical laboratory managers in developed nations, the ongoing story of anatomic pathology errors in Canada is noteworthy, because it raises interesting questions. Dark Daily has spoken with histopathologists in several different nations who put forth such questions as these:

• Among developed nations, why is Canada unique in that, since 2005, it has publicly acknowledged the discovery of multiple instances of unacceptable rates of diagnostic errors by pathologists in different provinces?
• Alternatively, might it be true that other developed nations are experiencing diagnostic errors in anatomic pathology in ways similar to the events in Canada, but these errors either go undetected or are never disclosed to the public?
• What lack of quality standards and medical laboratory accreditation requirements, both at the federal and province level, might contribute to the failure of the different provincial health systems in Canada to be faster at uncovering sources of pathology errors?
• Alternatively, could the quality and laboratory accreditation requirements in place in other developed nations be deficient in ways that mean diagnostic errors in pathology testing in these nations go undetected or undisclosed to the public?

In Canada, it was the disclosure of systemic diagnostic errors in the anatomic pathology laboratory of St Johns, Newfoundland, between 1999 and 2005—and the harm to hundreds of women with breast cancer tested by that lab—that made this a headline story with the Canadian public. Since that time, health officials in different provinces appear to be responding quickly to evidence that an individual pathologist may be failing to meet quality standards.

What might distinguish Canada from other developed nations, in terms of the public record of pathology misdiagnoses, is that the Canadian public is now sensitized to this issue. After, all, in almost every modern society, the public assumes that all clinical laboratories and histopathology laboratories perform testing with near-perfect accuracy.

Thus, the discovery of systemic diagnostic errors by an individual pathologist or a specific laboratory organization is exactly the type of news that quickly rockets into national headlines. It is newsworthy that a woman may have had her breasts removed unnecessarily because of a pathologist’s error. Or that, because the pathologist missed an obvious case of prostate cancer, that man’s cancer has now progressed to an incurable stage. People read these stories and think, “That could be me or someone in my family!”

For these reasons, the events unfolding in Canada are instructive for clinical laboratory managers and pathologists in every nation across the globe. This nation appears to be operating with a transparency about diagnostic errors that is at a higher level than in peer nations.

In that regard, it must be noted that Canada, like every other developed nation, faces the challenge of adequately funding healthcare services to maintain the level of access and the integrity of clinical services to which every patient has a right. From that perspective, some of these episodes of diagnostic errors reflect that delicate balance.

Trim pathology budgets too much over too many years, and the ability of the lab testing profession to maintain acceptable quality and accuracy of lab test results will be degraded. This is particularly true in communities where the volume of lab testing specimens increases by double digits each year and funding for lab services does not keep pace.

Thus, one “elephant in the room” for anatomic pathology in Canada is how the cumulative effect of two decades of reductions in budgets for these diagnostic testing services may have a role in the different reported instances of unacceptable error rates by individual pathologists in different provinces.

Related Information:

Alberta doc misdiagnoses at least 15 prostate cancer patients

Alberta pathologist’s mistakes launch huge review

Error in medical tests in Drumheller prompts provincewide review: Third time in two months that investigation launched into patient results

Woe, Canada: Now Imaging Errors Hit Alberta

Botched medical tests prompt Alberta to order sweeping review

Alberta needs better oversight to end medical errors, top doctor says

Commission of Inquiry on Hormone Receptor Testing; the Cameron Report

In Bristol, England, Errors in Anatomic Pathology Is an Issue That Refuses to Die