New measures to strengthen physician hiring and oversight and enhance public confidence in the health-care system were announced by Health Minister Michael de Jong, as he released the final report into a review of the quality of medical scans in British Columbia.

The review was launched in February by Dr. Doug Cochrane, chair of the BC Patient Safety and Quality Council, after concerns were raised around the quality of medical scans interpreted by four radiologists practicing primarily in Powell River, Comox and the Fraser Valley. The process included health authority reviews of thousands of CT scans and obstetrical ultrasounds.

While Dr. Cochrane's first report provided assurance that all remaining radiologists in the province were appropriately qualified, he concluded that similar events could occur in the future unless steps are taken to help close the gaps in the existing safeguards around physician practice.

In response to those concerns, the Ministry of Health has developed an action plan that includes:

• Implementing a timely peer review system for diagnostic imaging across the province - starting with immediate action to enhance oversight of newly privileged radiologists including locums and doctors with provisional licences.
• Establishing a common electronic provincial physician registry accessible to the College of Physicians and Surgeons of British Columbia, health authorities and the Ministry of Health to track current information about physician licensing, credentials and privileges.
• Creating consistent rules around communication and patient notification when adverse events occur.

While the report determined few patients sustained direct harm as a result of the incidents and the health authorities responded quickly to initiate corrective action, the report noted that the events shook the confidence of patients in many communities.

The report contains 35 recommendations directed to health authorities, the College of Physicians and Surgeons of British Columbia and the Ministry of Health. The recommendations focus on ensuring that doctors who want to practice in B.C. are screened appropriately, that their skills are assessed on an ongoing basis and that there are clear lines of accountability amongst all of the parties with a responsibility for protecting patient safety.

The Ministry of Health has accepted each of the recommendations of the report and will be working with the College of Physicians and Surgeons of British Columbia and health authorities to implement them.

Quotes:

Dr. Doug Cochrane, chair of the BC Patient Safety & Quality Council -

"I believe the action plan is an appropriate response given the seriousness of the events and their impacts on patients and their families. While this report looked at four unique events, the lessons learned are applicable across the health care system. I'm encouraged that work is already underway to ensure such incidents never happen again, it's important that all parties act quickly to strengthen the checks and balances in support of physician practice and care for British Columbians."

Dr. Heidi Oetter, registrar, College of Physicians and Surgeons of B.C. -

"The college fully understands the need for public confidence in ensuring the skill and competence of the physicians practising in the province - not just when a licence is initially granted, but throughout a physician's professional work life. This is one of the college's fundamental responsibilities and we take it very seriously. These unfortunate events have provided an opportunity for us to review and strengthen our internal processes, including the way information is exchanged between the college and the health authorities - and to make quality improvements where necessary."

Learn More:

The final report is available online at: www.health.gov.bc.ca/cpa/mediasite/.

Three backgrounders follow.

Media Contacts:

Ryan Jabs, Media Relations Manager
Ministry of Health
250 952-1887 (media line)

Christina Krause
Executive Director
BC Patient Safety & Quality Council
250 490-6994

Susan Prins
Director of Communications
BC College of Physicians and Surgeons
604 694-6129

BACKGROUNDER 1

Sept. 27, 2011 Ministry of Health

Ministry of Health: Action Plan

Below is a copy of the Province's Action Plan:

The Ministry of Health (the Ministry) has had the opportunity to review and consider all the recommendations provided by Dr. Cochrane through his Phase 2 report Investigation into Medical Imaging Credentialing and Quality Assurance and intends to work with health authorities, the College to address the address specific gaps and recommendations from the report. Regular public reporting on progress will be provided. The Ministry also intends to go beyond the report recommendations and so has developed an additional series of action items aimed to further enhance the quality of medical care across British Columbia (BC). These items, outlined below, are divided into those of specific importance to diagnostic radiology, and those intended to have a more systemic impact across various areas of specialization.

Diagnostic radiology

1. Radiology Peer Review and Support: Continue implementation of timely radiology peer review system beginning with immediate action to enhance peer support and oversight for newly privileged radiologists (including new locums), physicians on provisional licensure, and those newly trained in an imaging or interventional modality.

Ensuring quality of medical care in BC

2. Provincial Physician Registry: Establish a common provincial system, linked to the College of Physicians and Surgeons of BC (the College), and health authorities, to contain consistent and current information about licensing, credentials, and privileges. This will include initiating methods for public reporting and an opportunity for feedback from the public on such reports.

3. Provincial framework for physician credentials: Establish dedicated action team to work with physicians, the College, and HAs to develop a provincial framework for assessing physician credentials (training, experience, performance) and for granting privileges, beginning with radiology and anaesthesia.

4. Review of provincial system: Along with the support of the College and HAs, the Ministry will conduct a review of the provincial system to ensure that physicians in BC, both current and future, are qualified and competent.

5. Accountability for denominational facilities: Strengthen accountability between the Ministry, HAs, and denominational facilities to clarify roles and authority in terms of quality and patient safety matters.

6. Provincial protocol for future adverse events: Establish consistent provincial protocol for reviewing and responding to large scale future adverse events, including communication to patients and the public.

7. Performance Assessment Review: Work with health authorities and College to put in place a consistent provincial physician performance review process for ongoing assessment of competency.

Media contact:

Ryan Jabs
Media Relations Manager
Ministry of Health
250 952-1887 (media line)

BACKGROUNDER 2

Sept. 27, 2011 Ministry of Health

Update on health authority investigations

The quality of medical scans interpreted by four radiologists has been called into question during the course of the investigation to date. In all cases, health authorities are working with radiologists and other physicians to review test results and determine whether follow-up with patients is required. In total, the health authorities re-read approximately 14,000 CT, x-ray and mammogram scans. All patients requiring follow-up are being or have been contacted directly by health officials.

Radiologist #1 - Powell River: Vancouver Coastal Health has re-read 891 CT scans for 774 unique patients, which were originally read by a radiologist at Powell River General Hospital between April and October 2010. Of the 891 CT scans re-read, VCH found 152 discrepancies and have followed-up directly with each of these patients and their physicians. The health authority also reviewed 594 X-rays read by this physician and found 19 discrepancies. They have followed up with each of these patients and their physicians. VCH also reviewed 2,295 obstetrical ultrasounds performed on all women who were expecting in the Powell River area. The women have all been re-scanned, and those scans read by an accredited radiologist. Chart reviews were conducted of some earlier obstetric ultrasound cases where concerns had been raised, and the health authority is satisfied that no medical errors occurred. Patients who do not receive a letter or telephone call can be reassured they are not affected by this review.

Radiologist #2 - Fraser Valley East/Cranbrook: Fraser Health has re-read 174 CT scans read by a radiologist who practised as a locum at Abbotsford Regional Hospital and Chilliwack General Hospital in August and September 2010. Fraser Health found 11 discrepancies and has followed-up with each of these patients and their physicians. One patient experienced a delay in care as a result of the discrepancies identified; however, the treatment plan was not altered. Patients who did not receive a letter or telephone call should be reassured they are not affected by this review.

This radiologist also temporarily worked at East Kootenay Regional Hospital in September and October 2010. Interior Health re-read just over 200 CT scans that this radiologist read at this hospital immediately after he left and found no clinically significant discrepancies.

Radiologist #3 - St. Joseph's Hospital: St. Joseph's Hospital, in partnership with the Vancouver Island Health Authority, has re-read 2,721 CT scans on 2,312 patients, which were read by a radiologist between August 2009 and January 2011. They have found 180 discrepancies and have followed-up with each of these patients and their physicians in April or May of this year. While there is no indication of a pattern of concern for x-rays, mammography or ultrasounds, a quality-assurance review was completed on these scans. Of the 1,875 mammograms reviewed, 1,751 showed no abnormalities and 124 required further follow-up.

Of these, further diagnostic assessment was needed for 20 patients, and physicians will continue to monitor these patients. However, Dr. Cochrane concluded that these results indicate an acceptable performance of a screening radiologist. The hospital and health authority also reviewed 1,228 other scans (Radiographs: 905; Fluoroscopes: 42; Mammograms: 52; Cardiac Ultrasound: 229) that this radiologist performed and concluded there were no significant missed or misinterpreted scans.

This radiologist had also worked on a temporary basis at the Dawson Creek Hospital in June 2010, providing services to patients from Fort St. John, Dawson Creek and surrounding areas. Northern Health has reviewed 100 CT scans read by this radiologist. The health authority found seven significant discrepancies and has following up with each of these patients and their physicians.

Radiologist #4 - Ridge Meadows Hospital: Fraser Health re-read 199 out of 407 CT scans read by a locum radiologist working out of Ridge Meadows Hospital between November 2010 and March, 2011. As previously reported in March, nine major discrepancies were noted and based on clinical follow-up, none of the patients came to any harm. Fraser Health also reviewed the x-rays and 184 diagnostic mammograms and 2,971 x-rays that were interpreted by this radiologist at RMH and found that no harm was caused to any patient.

The radiologist also practised from November 2008 to October 2009 in the Fraser Valley. FHA reviewed approximately 810 CT scans read by this radiologist during this period and will follow-up directly with any affected patients and their physicians. There was only one case where there was evidence of harm to a patient as a result of discrepancies identified during by the review. The patient had an unnecessary surgical procedure and the result was non life-threatening. Patients who do not receive a letter or phone call can be reassured they are not affected by this review.

Media contacts:

Trudi Beutel
Public Affairs Officer
Vancouver Coastal Health
604 708-5282
604 812-1847 (cell)
Trudi.Beutel@vch.ca Fraser Health Media
Pager 604 450-7881

Suzanne Germain
Vancouver Island Health Authority
250 370-8294 Northern Health Authority Media
Media line: 250 961-7724

BACKGROUNDER 3

Sept. 27, 2011 Ministry of Health

Dr. Doug Cochrane - Biography

Dr. Cochrane is the chair and Provincial Patient Safety & Quality Officer of the BC Patient Safety & Quality Council, and chair of the Canadian Patient Safety Institute.

Dr. Cochrane is a professor at the University of British Columbia in Neurosurgery, a certificant of the American Board of Pediatric Neurological Surgery, and a fellow of the American Academy of Pediatrics.

Dr. Cochrane obtained his medical degree from the University of Toronto, graduating in 1975, followed by training in neurosurgery at the University of Calgary. A pediatric neurosurgery fellowship at the Hospital for Sick Children, University of Toronto, was completed in 1981.

Following his training, Dr. Cochrane was appointed as neurosurgeon at the Calgary General Hospital, Foothills Provincial Hospital, Tom Baker Cancer Center and Alberta Children's Hospital, and served these facilities until 1986. During this time, he held an appointment as assistant professor of neurosciences, University of Calgary.

In 1986, Dr. Cochrane was appointed as a staff neurosurgeon at British Columbia's Children's Hospital and Sunny Hill Health Centre for Children. He served as the head of the section of surgery and surgeon-in-chief, British Columbia's Children's Hospital and Children's and Women's Health Centre of British Columbia 1991-2001, vice president of medicine for Children's and Women's Health Centre of British Columbia 2001-2003, and vice president of medical affairs, quality, safety and risk management for the Provincial Health Services Authority in Vancouver 2003-2008.

Media Contacts:

Christina Krause
Executive Director
BC Patient Safety & Quality Council
250 490-6994

Ryan Jabs
Media Relations Manager
Ministry of Health
250 952-1887 (media line)