Better training needed, says watchdog after Alberta health system misfiled tissue samples

Dr. John Cowell, CEO for the Health Quality Council of Alberta speaks to the media



CALGARY - A health care watchdog says better assessment and training is needed after nearly 200 tissue samples were incorrectly processed through Alberta's medical system.

Equipment used to process the samples that can detect cancers is error-prone, while whistleblowers in the area should be protected, Dr. John Cowell, CEO of the Health Quality Council of Alberta (HQCA), said Thursday.

In 2010-2011, Cowell noted 31 tissue samples handled between Calgary Laboratory Services and the Rockyview General Hospital were processed incorrectly. A further 159 prostate samples were red-flagged coming out of Edmonton's Royal Alexandra Hospital in 2011, he added.

"Such events are of great concern and warrant review," Cowell told reporters.

"This is not to lay blame but to look forward."

While Alberta Health Services says no unnecessary operations resulted from the mistakes, Cowell said better vetting and monitoring of pathologists conducting the tests is needed.

"We recommend the college of Physicians and Surgeons co-ordinate their approach in assessing pathologists' competence and performance," he said.

In the Edmonton cases, he said, an assumption was wrongly made that a pathologist hired on the basis of previous experience was qualified to take on the task, leading to dozens of errors.

"We felt the hiring process was too casual," he said.

The HQCA report also zeroed in on sample processing equipment, vulnerable to human error.

Cowell said procedures using the equipment should be tightened and that their operators request manufacturers to improve the product.

There's also a lack of co-ordination between health agencies in the tissue sample process and a potential conflict of interest in funding and accrediting pathologists, the HQCA stated.

Alberta Health Services Dr. Verna Yiu said those prepared to come forward with internal complaints need to be protected.

"We need to provide an environment free of intimidation - that is critical to our commitment to improvement," she said.

And Yiu said many of the recommendations made by the council have been or are being addressed.

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