The re-read of 68,360 general radiology, CT, mammography and ultrasound exams is now complete in Sunrise Health Region. The re-reads were ordered in May 2009 as a patient safety precaution. Notifications were sent to advise 24,990 patients of radiologist re-reads for exams originally read by Dr. L. Darius Tsatsi. Concerns identified by the College of Physicians and Surgeons of Saskatchewan had sparked the review. Dr. Tsatsi is no longer licensed to practice radiology in Saskatchewan.
Radiologists from outside the health region were hired to re-read the exams for a second interpretation. A difference of interpretation was noted in 12,871 exams (18.8%). Of these 10,883 (15.92%) were substantially correct with minor discordances and 1,988 exams (2.91%) were considered to have the potential to affect patient care.
All of the patients whose exams were part of the review have been contacted, with the exception of those with no known mailing address. The health region will continue attempts to reach these people through the month of July. Family physicians have received the second interpretation and, when appropriate, reviewed the information with their patient. To date, family physicians have reported that 432 of the new interpretations had clinical significance that was followed up with the patient or had received previous attention.
"Radiology is an important diagnostic tool but it is not the only resource that physicians use to achieve a diagnosis," says Chief Executive Officer, Joe Kirwan. "As the review progressed we found that even when a difference in interpretation was identified, many patients had received the care they needed through other means."
The Province of Saskatchewan has picked up the full cost of the review expected to be close to $4 million dollars. The exams were re-read outside of the health region by approximately 85 Royal College Certified radiologists. The radiology department and administration staff in Sunrise Health Region shouldered coordination of the process while maintaining the ongoing services of the health region. Compiling of information to be re-read, retrieval of files and sending of letters to physicians and patients resulted in more than 26,000 hours of staff time in Sunrise Health Region, over and above the staffing needed for day-to-day operations.
"The experience was difficult for patients," says Kirwan. "Concerns for patient safety necessitated thorough review and the associated costs were worthwhile if patients received treatment they may have otherwise missed."
The health region is working internally and with provincial colleagues to apply the knowledge gained during the review so that concerns are caught more quickly and processes are improved to advance patient safety in Saskatchewan.
