EDITORIALS Delays failed patients

Patients and families have every right to be concerned and angry at last week’s report on a radiologist who worked at hospitals across the province — including Vancouver Island — despite serious performance problems. Errors are part of medicine, including errors in reading CT scans, MRIs and other medical imaging. Radiologists use their best judgment, but two doctors can look at the same scan and reach different conclusions.

But patients have a right to expect a system that monitors doctors’ performance, provides guidance that allows them to improve and, when necessary, weeds out those whose skills are inadequate.

That was the promise in 2011, after a review of four radiologists found errors had contributed to the deaths of at least three British Columbians and affected the treatments for many more.

That review, by Dr. Doug Cochrane, chairman of the B.C. Patient Safety and Quality Council, made recommendations to address the problems. Mike de Jong, then the health minister, apologized to families and promised all the recommendations would be implemented.

But six years later, the measures recommended by Cochrane to help radiologists and improve patient safety are still incomplete.

The latest review by Dr. Martin Wale was sparked by concerns about the work of Dr. Claude Vezina, who had practised in Ontario before spending six years in a string of short-term placements in this province. The first serious alarm about his work was raised by a colleague.

That led to a review of a random sample of 22 scans he had read. Errors were found in almost half. A further review of his work, which is continuing, led to hundreds of patients on Vancouver Island being notified about possible problems with their diagnoses and treatment.

Again, errors happen. But this case reveals a systemic failure.

Vezina was working in this province in a series of locum positions, filling in for radiologists who were away or during a staff shortage. He applied for permanent positions in Powell River, Nanaimo and Victoria, and was rejected, despite a shortage of radiologists.

But the reasons were never shared, and he continued to be hired by B.C. hospitals.

Wale’s review reveals troubling gaps in the system. Key information about Vezina’s work was not shared as he moved from hospital to hospital.

“Concerns about privacy and working relationships limit the ability to seek information, even when this impacts patient safety,” Wale found. “Present arrangements for locums do not track where an individual has worked or how his/her work was perceived.”

Almost one-third of the 42 recommendations from the 2011 review are still not in place, Wale found. Critically, Vezina was not part of the promised Radiology Quality Improvement System in any of the four health authorities where he worked.

Errors are inevitable. But in this case, they were preventable. The government and health authorities knew what needed to be done and had promised six years ago to act.

Their delays and foot-dragging failed patients.