11 patients linked to Trillium Health radiologist have healthcare issues

Hamilton Spectator

By Theresa Boyle

Dec 06, 2013

 

A Mississauga radiologist's errors contributed to delays in diagnosing and treating 11 patients, two of whom have died, a review of his work has concluded. 

"Some of them have been treated and are doing well, some of them are undergoing treatment and two of them are deceased," Dr. Dante Morra, chief of staff at Trillium Health Partners, said Thursday. 

An external review of Dr. Ivo "Ivan" Slezic's work was launched in September, after his superiors at the hospital picked up on some "performance issues."

The hospital would not confirm whether Houda Rafle was one of the deceased. The 28-year-old Toronto television producer died of cancer last week after Slezic allegedly missed seeing a tumour near her heart on a CT scan done in March.

Her family has filed a $2-million negligence suit against Slezic and Trillium. Hospital officials would not say whether there have been additional lawsuits arising from radiology errors. 

The external review was headed by Dr. Brian Yemen, chief of diagnostic imaging at Hamilton Health Sciences. He led a team of 17 radiologists in taking a second look at 3,537 CT scans and mammograms done by Slezic between April 1 last year and March 31 this year. 

They found that he made "errors in interpretation" — also known as "potentially clinically significant" errors — in 645 of them. 

That makes for an error rate of 18 per cent. Yemen noted that the suggested error rate accepted by the American College of Radiology is 2 per cent to 4 per cent. 

But the actual percentage of errors deemed "clinically significant," resulting in delays in diagnosis and treatment, turned out to be only 0.3 per cent and involved 11 patients. 

That's because problems with the other affected patients were picked up through other diagnostic tests and examinations, Yemen explained. 

"In some cases their prognosis was affected," Morra said of the 11 patients, refusing to offer any more specifics because of privacy concerns. 

Morra said it would be wrong to entirely blame any poor outcomes entirely on Slezic, because a patient's care typically involves a number of clinicians. 

"The report of a radiologist is only one part of a clinical scenario (that also includes a patient's) history, physical, other lab tests and other consultations with a variety of clinicians. You can't speculate as to the conditions and the impact that this one physician's practice had on any one of his personal cases," he said. 

Still, lawyer Paul Harte, who specializes in medical malpractice and other areas of health law, said the review confirms that there were serious issues with Slezic's diagnostic interpretations. 

"There can be little doubt that there was a serious systemic problem at Trillium Health Partners. The quality assurance processes in place at (the hospital) were clearly inadequate to protect their patients," he said. 

Hospital president Michelle DiEmanuele emphasized that the review found that in more than 99 per cent of scans, patients did not experience clinically significant events. 

Still, she apologized to those who experienced a delay in treatment. 

"I would like to thank our patients, their families and the community for their understanding and support during the past several months," she said. 

Trillium also announced it is beefing up quality assurance by implementing a formal peer-review program in its radiology department. 

Lawyer Duncan Embury said the Rafle family, whom he represents, is pleased to hear about the beefed-up quality assurance. 

"While we are not aware of the details of that review program, on behalf of the Rafle family we are hopeful that it will serve to prevent further needless tragedies," he said. 

Health Minister Deb Matthews announced Thursday that the province is also taking steps to improve quality assurance in radiology. The provincial body, Health Quality Ontario, will lead the implementation of a province-wide peer review program in all facilities where diagnostic imaging services are performed, she said. 

Torstar News Service

Source: http://www.thespec.com/news-story/4258808-11-patients-linked-to-trillium-health-radiologist-have-healthcare-issues/