A problem with a laboratory system has resulted in results errors for some patients.
© Herald photo by Jodi Schellenberg
Dr. Edmund Royeppen discusses a lab result error during a press conference on Thursday morning.
During a press conference held by the Prince Albert Parkland Health Region, senior medical office Dr. Edmund Royeppen explained an incident occurred with the laboratory system, resulting in 30 patients either having delayed results of incorrect information being sent to their physician.
“The essence of the error that occurred is the result of us moving to a new process,” Royeppen said.
Earlier this year, PAPHR moved to a provincial lab information system to get their results.
“Essentially, this allows all laboratory results for any investigation that occurred to be uploaded into a system and that allows physicians and other health-care providers to be able to access information on their patients,” Royeppen said. “What we found was that there was a delay in the results being send out to the physicians office. As a result of that, we launched an investigation and found, after a fairly extensive investigation, that a group of cytology results we either delayed in being sent out or there was a mismatch between the patient results and the patient’s information.”
Instead of having the lab tests being processed in Saskatchewan, they have been sending them out to an out-of-province lab service. The results are then sent back to PAPHR and have to be uploaded into the Laboratory Information System (LIS).
“The method that was being used was a cut and paste method,” Royeppen said. “It was a paper copy that we would then upload into the system. They get it into the LIS, we would have to cut and paste those results and match them to the patients.”
When the paper is transferred over to the electronic system, it is not as simple scanning and creating a PDF file.
“We face the problem where a paper copy has to be transferred into electronic form,” Royeppen said.
There were two defects that occurred, he said. The first was a cut and paste error where the wrong cytology results were put into a patient’s details. The second was a backlog from the new process resulting in a delay.
“After a fairly extensive investigation performed with the laboratory people and through quality management, we found there were 30 patients where there results delayed or error,” Royeppen said. “Six of these were incorrect information sent to the physicians and 24 of these were delays, so there was a delay in getting the results out to the family physicians. In seven of these there were abnormal results, so it was a delay in further testing.”
They have written to all the patients and physicians whom may have been affected by this error, he said, and they apologize for the error.
“We have gone back to the old process of receiving the information from the external laboratory source and we are now not uploading this into the LIS until we find a secure process to do that,” Royeppen said. “Instead what we are doing is sending out the information directly to the physicians who have requested.”
Although there have been delays and incorrect information sent out, Royeppen said they are fairly confident the error did not result in a significantly different outcome.
“There is potential for those seven patients to have a delay in further testing and further investigation,” Royeppen said. “Only the physicians who have handled those investigations would be able to say if that delay would result in a significantly different outcome for them. That is why we have written both to the patients and physicians saying here is the defect we have identified.”
The delay time only would have added an extra week onto the patient’s wait time, he said.
“What we do know is most cancers occur in a very slow growing. A short delay doesn’t truly affect a patient’s outcome,” Royeppen said. “We wouldn’t want to preempt that and say to all the patients involved that we don’t think there is anything adverse that could occur. We would rather the physicians decide that and manage it appropriately.”
He also said it isn’t any one person’s fault that this error occurred and no employee is being disciplined for the system error.
“The error was the result of a requirement to use a new process including these results into the LIS,” Royeppen said. “The error was made collectively. The idea is not to target any individual but look at what our process has been in terms of defects that have been created and rectify those.”
They hope to find a new system or process to replace the one previously used.
“When we are going to a new system or going to a new process, we would like to be able to error proof that process while we are building it,” Royeppen said. “(We would like to) run and test it in a very short period of time and know it is not going to create a new error.”