Health officials in Canada's Saskatchewan province have discovered that its regional radiology information system failed to have nearly 1,400 radiology reports faxed to referring physicians over the past 10 years.
The computer error was discovered on May 6, when a physician called the Saskatoon Health Region's medical imaging records department to ask why a patient's test results had not been faxed to his office. Upon investigation, administrators discovered that the automated order to fax contained an empty field where a telephone number should have been, placing the order in a void where it could not be detected.
Daily quality control verifications that match faxes sent with faxes received did not contain fax orders with blank telephone numbers, regional media relations representative Linda Miller told AuntMinnie.com in a telephone interview.
"These orders were invisible to the computer, which interpreted that they did not exist," she said. "Because there was no telephone number to match against telephone numbers that had successfully received the faxed report, or to match against telephone numbers that for whatever reason did not have a successful completion, the computer did not acknowledge their existence."
After the computer error was identified, administrators searched the entire RIS database since its installation in 1999 to identify patient files with automatic orders for faxing reports that contained a blank field for the fax number.
When the search was completed, a total of 1,380 reports were identified, or approximately 0.06% of the total. The reports originated from the radiology departments of the health region's three hospitals in Saskatoon: Royal University Hospital, Saskatoon City Hospital, and St. Paul's Hospital. The system successfully transmitted at least 2.2 million other radiology reports during this time.
The health region notified the media of the computer error, established a dedicated customer service telephone line for patient inquiries, and began the process of telephoning all the referring physicians who had not received the faxed reports, as well as patients. As of May 25, 298 physicians had been contacted to determine if they had received their patients' diagnostic imaging results, either by accessing the patient's records through the regional Web server or by telephoning for results themselves.
At a press conference held May 22, Dr. David Poulin, Saskatoon Regional Health Authority's vice president of medical affairs, and Sandra Blevins, vice president of clinical and operations support, declined to say if any patient's health had been jeopardized, according to a report in the StarPhoenix.
Poulin suggested it would be a good practice for physician offices to have a system to check whether they had received important medical reports and results of lab tests they had ordered for patients.
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