The Ontario government may consider issuing a directive to hospitals to check their pathology reports in light of revelations that a surgeon at a Windsor hospital performed unnecessary mastectomies on at least two women.
"I think everybody is paying attention to this right now. I think every hospital is always trying to improve their level of patient care and they are taking the appropriate steps," Ontario Health Minister Deb Matthews told reporters on Thursday. "We have not yet issued a directive but it's something we might do."
Matthews added that the province will also be conducting an external review of the situation at Windsor's Hôtel-Dieu Grace Hospital.
"We think it's important and [the hospital] thinks it's important that we have people from outside the hospital take a look so that we all know what happened — what lessons we have learned and what else we need to do to prevent this from happening in the future."
Thousands of medical cases are currently under review at three hospitals in southwestern Ontario following the suspension of a pathologist.
Hôtel-Dieu Grace Hospital in Windsor suspended Dr. Olive Williams on Jan. 4, and reported her to the College of Physicians and Surgeons.
Williams also provided pathology services to Windsor Regional Hospital and Leamington District Memorial Hospital.
Hôtel-Dieu Grace is leading a review of more than 15,000 cases dating back to August 2003, when Williams was hired to work at the region's laboratory partner, Windsor Essex Pathology Associates.
Windsor Regional Hospital announced late Wednesday that it has already completed a four-day investigation into the work the pathologist performed for its patients during a six-week period in late 2009.
'This pathology review was prompted by a recent adverse medical event, and other errors discovered in pathology reports to date."—Dr. Kevin Tracey, Hôtel-Dieu Grace Hospital
The review of 171 cases "concluded that there are no issues of clinical significance related to those Windsor Regional Hospital patients," hospital spokesman Ron Foster said in a statement.
Surgeon misreads pathology report
The suspension of Williams was only made public after it was revealed a surgeon at Hôtel-Dieu Grace Hospital had performed mastectomies on at least two women who did not have cancer.
Dr. Barbara Heartwell removed a breast from one patient after misreading a pathology report.
In the second case, a mastectomy patient learned after her surgery that a pathology report stating she didn't have cancer was available to her surgeon, but Heartwell contends she did not see that report.
Heartwell has since been suspended, reported to the College of Physicians and Surgeons, ceased performing surgeries and has her entire mastectomy case history under review.
Hospital uncovers 7 'cases of concern'
Officials at Hôtel-Dieu Grace Hospital said they have so far found seven "serious cases of concern" connected to Heartwell, but added that the problems may be related to pathology reports.
"This pathology review was prompted by a recent adverse medical event, and other errors discovered in pathology reports to date," said Dr. Kevin Tracey, interim chief of staff at the hospital.
Tracey would only say a patient was seriously harmed in November, but wouldn't provide details.
He said some of the cases of pathology errors involve mastectomies and others don't.
"Patient confidentiality prevents us at this time from disclosing details of individual cases," said Tracey.
"However, we can tell you that all affected patients have been made aware by the physicians involved."
Tracey stressed that news reports about the mistaken mastectomies did not prompt the review of the Williams's work, a process that began in November.
Provincewide policy change
Matthews said a new provincewide policy to be introduced in April should help prevent errors in pathology and surgery.
"Everyone will go through a checklist," said Deb Matthews.
"One of the elements in that checklist, before the anesthetic is given, is a double-check of the biopsy results. So this horrible example just underlines the importance that we move forward quickly on this strategy."