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UPDATE: Doctors received incorrect information in Prince Albert Parkland Health Region

Oct 31, 2013 | 12:05 PM

A recent delay in the return of lab information in the Prince Albert Parkland Health Region (PAPHR) led to an unfortunate discovery.

The health care of 30 patients has been affected by a failure to properly transfer patient laboratory results.

At news conference called on Thursday, the PAPHR said lab information was either incorrectly entered and sent back to their physicians or was delayed.

This happened to results of patients tested between Sept. 9 and Oct. 21.

These errors were discovered after an extensive investigation into one delay, which was reported by a physician’s office, said Dr. Edmund Royeppen, senior medical officer with PAPHR.

The issue was taken seriously because it revolved around cytology results, which tests for abnormal cells in fluids using a microscope, which are usually conducted to test if a patient has a bladder or thyroid cancer, said Royeppen.

The PAPHR has been sending specimens out of province to be assessed.

What this means to the 30 patients

Upon investigation, the health region found that doctors received the wrong information in lab results for six patients.

In addition, lab results were created but not sent to the physician for 24 patients in a timely fashion.

Of the 30 people involved in this overall error, seven of their tests were abnormal. This means diagnosis of illness was delayed in those seven cases.

However, Royeppen said it is unlikely any of those patients were led to believe they either did or did not have a serious disease like cancer.

“We are fairly certain that there was no misdiagnosis as such. Those investigations that were ‘cut and pasted’ were actually, most of those were normal results.”

He said there was a potential for a compromise that leads to adverse patient outcome.

Only the physician involved in those cases can tell if the outcomes for those patients are significant, said Royeppen.

The patients and their physicians have all been informed of the situation.

How did it happen?

“The essence of the error that has occurred is as a result of us going to a new process,” said Royeppen.

The new process was adopted earlier this year. It is a provincial lab information system that allows doctors and healthcare professionals to access all laboratory results for their patients.

The system provides an electronic health record.

The error occurred when the results from those laboratory tests were entered into that system after they came back from the out-of-province service.

There were two issues stemming from this.

First, those results were uploaded into the information system using a ‘cut and paste’ computerized method to match the results with the patients, he explained.

This means a particular patient’s details were matched to the wrong cytology results, which caused the instances where the physicians received incorrect information.

Second, the transition to the new system resulted in a backlog in sending out results to patients and their physicians.

While the electronic information was entered incorrectly, there were also faxes sent, which were accurate.

The new system is clearly not error-proof, said Royeppen.

However, he didn’t lay responsibility for the error on any specific person, so no one will be fired.

Rather he said it was collectively made in how the laboratory process has been managed.

“Going forward, I think the big learning for us is that when we’re going to a new system, when we’re generating a new system we would like to be able to error-proof that process while we are building that process.”

Until that system can be remedied, they have returned to the old method of entering test results, which does not include uploading the results.

“We have subsequently written to all of these patients, all 30 of these patients, and we’re written to their physicians informing them of the error. The region is sincerely regretful and apologizes for the error being performed.”

claskowski@panow.com

On Twitter: @chelsealaskowski.