Ten-year-old computer glitch prevents delivery of 1,380 Canadian health results

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Sunday, May 24, 2009

The Saskatoon Health Region in Saskatchewan, Canada recently discovered a fax machine problem which had not relayed almost 1,500 X-rays, Computed tomography (CT) and Magnetic resonance imaging (MRI) scans, ultrasounds, and other medical imaging test results to doctors.

Image: Royal University Hospital Julia Adamson.

The fax machine is part of the automated Radiology Information System. An audit revealed that medical diagnostic tests involving results dating back a decade have been affected by the broken fax machine.

On May 6, a doctor called the health region officials seeking follow up on a patient's report. Staff who delved into it, found that the report was not sent from the system.

Now, two weeks later, this same patient has still not been contacted by the health region.

Typical screen layout of Computed tomography (CT) software used for reviewing multi-detector CT studies.

"It has taken some time to work with the patient's physician. That was important — to get more information and more detail because we want that patient's physician to be involved in the discussion with the patient," Dr. David Poulin, vice-president of medical affairs for The Saskatoon Health Region, said. "This is a system error and that's just what it was — an error. This doesn't reflect in any way on the quality of work regional staff have done and continue to do."

An internal review revealed that, of 2.2 million diagnostic tests performed, at least 1,380 had not been sent out by the malfunctioning fax machine.

The health region will embark on contacting each of the 1,380 patients and their physicians to make sure that the results have been received and if any health care was compromised.

Patients can also contact the health region via a newly set up hotline to make enquiries.

"We think it would actually be good practice if physician offices could have a system to check whether they have received important reports," said Poulin, "The common practice appears to be in many doctors' offices, particularly family physician offices, that they don't respond to the report until it arrives. So, they basically are waiting for the report to arrive in their office by fax and it's at that point that they look at it and decide what action to take."

City Hospital, St. Paul's Hospital and Royal University Hospital were the three city hospitals affected. Saskatoon has a population of roughly 233,923, and the hospitals also serve the surrounding rural areas.

Ironically the faulty fax machine was discovered the same week that provincial medical officials began to review approximately 70,000 radiology tests conducted in Yorkton. Officials there doubt the competence of the physician who first interpreted the radiology results.