YET ONE MORE TIME, pathology errors are making national headlines in Canada. News of errors by a surgeon and a pathologist in a Windsor, Ontario, hospital caught provincial health officials off balance.
The simple story is that an experienced surgeon at 305-bed Hotel-Dieu Grace Hospital performed a mastectomy on a patient that did not have breast cancer. The surgery happened because the surgeon, Dr. Barbara Hartwell, misread the pathology report.
A Complex Story
The details of the story are more complex. First, the pathology report was described as “confusing,” one reason why Hartwell says she “misread” the pathologist’s findings. Second, it was reported that Hartwell had a second report prior to surgery that said the patient was negative for breast cancer, thus raising more questions about why she didn’t catch this error prior to surgery.
Third, the pathologist, Dr. Olive Williams from Windsor Essex Pathology Associates, had been issued a written caution by the College of Physicians and Surgeons (CPSO) in November 2009— the same month as the unnecessary mastectomy was performed—after having admitted that, in 2007, she missed reviewing a slide that showed an obvious tumor of the appendix. That patient was later properly diagnosed.
Fourth, the mastectomy was performed on November 5, 2009 and the error was communicated to the patient within days. Yet hospital executives remained unaware of this case until contacted by a local television news reporter about the error on February 5, 2010.
Fifth, however, within days of the mastectomy, the chief pathologist at Hotel-Dieu Grace Hospital learned of the adverse event and a review of Williams’ pathology cases was conducted. Press reports say that seven cases of “serious concern” were identified and Williams lost her privileges at Hotel-Dieu Grace Hospital on January 4, 2009.
Sixth, another patient who suffered an unnecessary mastectomy went public with her story. After Laurie Johnston of Leamington, Ontario, who was the patient in the November case, identified herself to the media, another patient came forward. Janice Laporte publicly stated that Dr. Hartwell had performed a mastectomy on her in September 2001, then told her a week later that she had been cancer-free prior to the surgery.
This steady series of disclosures has fueled almost daily headlines about problems with pathology testing. Hotel-Dieu Grace Hospital quickly decided to review 15,000 pathology reports handled by Williams since she began service there in 2003.
At the provincial level, the Ministry of Health has appointed three physicians to conduct a review that will include 3,000 pathology cases that go back two years. Leading the team is Dr. Barry McLellan, currently CEO of Sunnybrook Health Sciences Centre in Toronto and formerly the Chief Coroner of Ontario.
Meanwhile, some credible critics say that the review of pathology problems doesn’t go far enough. Tom Closson, President of the Ontario Hospital Association, wants a full, province-wide review of pathology cases, arguing that there is a lack of consistent standards in how pathology is performed across the province and a shortage of pathologists.
“We’d like to see a broader pathology review in Ontario,” Closson told reporters. “We’ve seen a number of examples over the last few years of false positives or negatives.” Calling pathology an “inexact science” which could contribute to misinterpretations of some specimens, Closson asked “Are we sure that we have a consistent approach to doing peer review—one pathologist looking at another pathologist’s work? I think the answer to that question is ‘no’!”
Response To Clossen
In responding to Closson’s remarks, Dr. Laurette Geldenhuys, President of the Canadian Association of Pathologists (CAP) talked to a reporter from the Vancouver Sun, who wrote that Geldenhuys “disagreed with Closson’s comments but conceded pathology is ‘an art as much it is a science.’”
“The practice of pathology in Canada is very good and Canadian pathologists are very well-trained,” noted Geldenhuys. “Of the hundreds of thousands of reports that go out, virtually all of them are of exceptional quality.”
In recent years, the Canadian Association of Pathologists has repeatedly urged provincial health plans and the federal government to institute stricter laboratory accreditation requirements and quality standards. On their own initiative, pathologists have established several voluntary quality programs. (See TDR, May 18, 2009.)
The discovery of an unacceptable number of errors by a pathologist in Windsor is one more example that supports the argument that sustained underfunding of pathology services by health systems in Canada has begun to compromise quality, analytical integrity, and patient safety.
When Lab Budget Cuts Hurt
THE DARK REPORT has observed how ongoing, multi-year budget cuts for laboratory testing services eventually must reach the point where quality cannot be maintained, given the shortage of pathologists and the inadequate resources available to them to process and diagnose specimens with a high degree of proficiency. The increasing number of examples of unacceptable pathology errors in Canada may be the sign that its health system has finally reached this point.
Is Pathologist Overwork And Understaffing an Issue?
DOES ONTARIO HAVE AN ADEQUATE NUMBER OF PATHOLOGISTS to deliver a high quality and consistent service? This question has been asked by the press following the disclosure of pathology errors in at least one hospital in Windsor, Ontario.
Approximately 463 pathologists practice in the province. Currently 10 pathologists work in Windsor (not including Williams, who is suspended). Its two hospitals serve a population of 325,00 in the Windsor metropolitan area.
Ontario Health Minister Deb Matthews told a reporter that government funding for pathology training positions has increased. In 2003, just seven pathologists were in training. The increased funding now supports 28 pathologist training positions. However, across Canada, a number of pathology residence positions go unfilled each year.