Formal radiology peer review will be implemented across the province of Ontario after an 18.2% discrepancy rate was uncovered in an external review of images read by Ontario radiologist Dr. Ivo Slezic.
The review's findings were released on December 5 by Trillium Health Partners, for whom Slezic worked.
"Health Quality Ontario will lead the implementation of a province-wide physician peer-review program in all facilities where diagnostic imaging services are provided, including mammograms and CT scans," announced Ontario Minister of Health and Long-Term Care Deb Matthews on the same day. Very few hospitals in Ontario have a formal peer-review program in place.
The external review covered 3,537 CT scans and mammograms read by Slezic between April 1, 2012, and March 31, 2013, the last day he read images at Queensway Health Centre in Toronto and at Mississauga Hospital. The 17-radiologist review, led by Dr. Brian Yemen, was triggered by mistakes discovered in March through the hospitals' quality assurance program.
Yemen, who is the site chief for diagnostic imaging at Juravinski Hospital and Cancer Centre and McMaster University Medical Centre, reported discrepancies in 1,267 reports. About one-fifth -- 645 of 3,537 (18.2%) -- were found by the review team to be "potentially clinically significant."
The highest rate of potentially clinically significant discrepancies -- 22.1% -- was found in CT scans. Chart review, calls to the family physicians and specialists involved in each case, and follow-up patient testing revealed that as of November 28, 10 CT patients had experienced "clinically significant events" after Slezic misread their scans. There was a 1.8% rate of potentially clinically significant discrepancies in mammography reports, but as of November 28 only one patient experienced a clinically significant event as a result.
"We have fully disclosed the error to the [11] patients and their families. ... It would be inappropriate to speculate on what role this physician's practice may have played in their care," Carol Kotacka, Trillium Health Partners' director of communications and patient and community relations, told AuntMinnie.com in an email.
"We welcome and support the implementation of practices that will improve patient safety," she continued. "We have participated in province-wide discussions requested by the Minister of Health and Long-Term Care and look forward to working with them in the near future on this initiative."
