Test results in doubt
Central Health offering retesting to pulmonary function test patients
More than 100 patients at Central Health gasped for air this month when the health authority announced it found two patient safety issues, in its cardiopulmonary department at James Paton Memorial Regional Health Centre in Gander.
As a result of a malfunction with equipment used to calibrate pulmonary function test (PFT) machines, Central Health CEO Rosemarie Goodyear said 98 patients, who had PFTs completed between Jan. 13-Feb. 19, would need to be retested.
Ms. Goodyear said Central Health officials had attempted to contact these patients, with 80 consulted and offered the opportunity to be retested.
“The other 18 we weren’t able to talk to because of various reasons, such as being away on vacation, so if we’re not able to verbally speak to them in the next few days we will follow up in writing with them.
“The retesting is already ongoing, and we expect by the end of Friday (Mar. 21) to have close to half of these 98 completed. It’ll probably take about two weeks to completely finish, or at least offer everyone an opportunity to be retested within that time frame.”
As for the impact this particular delay in having a PFT completed on a patient, JPMRHC chief of medical staff Dr. Raj Brahmbhatt said it most likely is to be very minimal.
“The likelihood of any negative impact on patients as a result of this particular issue is anticipated to be minimal as PFTs are one of a number of tests used in conjunction with other clinical findings by physicians when making a diagnosis and/ or treatment plan.
“The impact on patients cannot be known with certainty until retesting has been completed.”
Ms. Goodyear said Central Health would provide an update to the public regarding any patient harm once everything is complete.
The second issue of patient safety coming to light in JPMRHC’s cardiopulmonary department dealt with Central Health’s distribution of Sleep Study reports.
Ms. Goodyear said “There was no issue with inaccuracies with the sleep tests ... the issue was in terms of insuring physician awareness around reports.” She noted there is no need for retesting. Ms. Goodyear claimed the issue was a result of Central Health consolidating an electronic clinical information system in April 2013, and while electronic versions of Sleep Study reports were available in this system to all but a small number of physicians, paper copies were not being printed and distributed to the ordering physician.
“Once this was discovered, Sleep Study reports began being printed and distributed to ordering physicians. We will also be sending correspondence to those patients as well to let them know there was potential their physician may not have viewed their report, and we have also brought this to their physician’s attention.”
In total Central Health reviewed 758 sleep studies, belonging to 719 patients, in its investigation, and of this, 93 per cent of these reports were normal and required no further investigation.
Of the remaining reports, there were initially 34 reports that had not been reviewed, with the status of 18 other reports undetermined.
According to Ms. Goodyear, the proper steps have been taken to correct this issue, as well as ordering physicians are in the process of determining if any unviewed reports have had any impact on patients.
Dr. Brahmbhatt said “We notified the physicians that if anyone had any concern about any of those tests to contact us and we would fit them in right away, and we haven’t yet received any such notification from any physician.”
Ms. Goodyear said, with the Sleep Study issue there was a concern with staff around the timeliness that the issue was brought to the attention of Central Health, and it has been discussed with staff.
“The issue has certainly been addressed, and the staff member is very aware of the issue of the timeline and the impact of the timeline may have potentially had on patients. At this point in time, it is still undetermined if indeed there is any patient impact, but we’re always dealing with potential, and the staff person is certainly aware in the terms of what the potential implications around that particular piece.
“I don’t see any reoccurring issues in that area.”
Ms. Goodyear said quality control and patient safety is of major concern to Central Health, and it is definitely an everyday priority.
“In health care, we have many complex processes and practices that have evolved over many years. That is why, through patient safety initiatives, we are examining the way we do things in a more focused and comprehensive way than we have ever before.
“Our continued and sustained focus on quality and patient safety means more issues are being brought forward. This creates opportunities to improve the system and the delivery of care. At Central Health, we are committed to continuous quality improvement, and safe patient care is our priority.”
Ms. Goodyear said Central Health apologizes to any patients who may have encountered or experienced any type undue hardship or unnecessary stress or worrying around these issues.