– We can see here, along the main artery, that there is an infill that should not have been there. Senior doctor Sven Weum at the children’s radiology department at UNN picks up a random examination of a child with cancer on his screens. When he and his colleagues admit such patients for the first time, the examinations often consist of several thousand images, says the senior doctor. – You can imagine a salami sausage that is cut into thin, thin slices. We can reconstruct these images in all possible directions afterwards, so that we can map where a tumor is, he says. It is not unusual for them to spend several hours going through the first examination of such a patient. Other examinations, such as a simple fracture in a wrist, can be done by an experienced doctor in only ten to twenty seconds. Sven Weum, senior physician in pediatric radiology at UNN in Tromsø. Photo: Simen Wingstad / news On Tuesday, news mentioned that a former substitute doctor at the X-ray department at the University Hospital of Northern Norway (UNN) is being investigated for being sloppy at work. Over several years, the man is said to have spent just a few seconds quality-assuring X-ray examinations of patients. Among other things, he is said to have overlooked a 3.5 centimeter tumor on the pancreas of a patient, after opening the examination for just twelve seconds. The patient later died, without UNN having uncovered any connection between translated X-ray findings and the cause of death. This is the case Until now, UNN has gone through 560 of the investigations the substitute doctor has been involved in between December 2021 and August 2023. In twelve of them, they have uncovered serious errors. Five of the patients have died, without the hospital being able to uncover a connection between the translated X-ray findings and the cause of death. The last seven have been reassessed, and some have carried out new investigations. UNN has concluded that the doctor’s sloppiness has not led to worsened prognoses for these patients. An internal notice at UNN in the autumn of 2023 led to the hospital discovering that the substitute doctor had spent what they refer to as an unreasonably short time to ensure the quality of X-rays. UNN reported the case to the State Administrator in Troms and Finnmark, who after a short time sent the case to the National Health Inspectorate. In December 2023, they decide to temporarily withdraw the doctor’s authorization as a doctor and specialist in radiology. – It is serious that a doctor who is supposed to do a thorough examination has not done so, says acting managing director at UNN Snorre Manskow Sollid to news. news has been in contact with the substitute doctor’s Norwegian lawyer, but he does not want to comment on the case at the present time. Nor has news succeeded in getting a response to repeated inquiries directly to the man. – Have to look at the pictures as, for the first time, Weum does not know about the case about the substitute doctor, other than from what he has read in the media. He therefore speaks on a general basis about how radiologists work to interpret examinations. The serious mistakes that the substitute doctor is being investigated for having made concern re-examinations, i.e. a review by a superior of assessments that a doctor in specialization has first made. These doctors are being trained to become specialists in radiology, and all examinations they describe must be reviewed by a senior doctor. Training as a specialist takes five years. – This means that we have to re-examine all the images again, as if we had received them for the first time, says Weum. – The only difference is that a specialist doctor has already described the images. We carefully review this text, and may make changes and additions. The substitute doctor worked for several years at the University Hospital of Northern Norway in Tromsø. Must get clarity on consequences for patients – It is clear that we see with horror that things are happening that can go beyond patient treatment and patient safety, says leader of the user committee at UNN Terje Olsen to news. Olsen will now ask that the user committee be briefed on the matter at the next meeting. – We are of course very concerned that the system works. After all, that is our role, to give advice to the director in relation to the feedback we receive and the observations we make about how the system works. Head of the user committee at UNN, Terje Olsen. Photo: Simen Wingstad / news – And beyond that, what do you expect UNN to do next in this case? – In this case, they must get clarity on what has happened, and not least on whether this may have had consequences for patients. – What do such cases have to say for trust in the hospital and for healthcare personnel? – I believe that patients, and the population in general, notice when errors occur in the health service. But I don’t think that means that people don’t trust the healthcare system. To go through 1,000 investigations UNN has already gone through 560 investigations the substitute doctor has been involved in, between December 2021 and August 2023. In twelve of them, serious errors have been uncovered. After the summer, UNN will examine more than 500 more examinations that the substitute doctor has approved. The case has been reported to the State Administrator in Troms and Finnmark, who after a short time sent the case to the National Health Inspectorate. In December 2023, they decide to temporarily withdraw the doctor’s authorization as a doctor and specialist in radiology. This CT machine is used to take X-ray examinations of patients. Photo: Mathias Sommerseth Kjellmo / news The Norwegian Health Authority will not comment on the case as long as it is still under consideration. – In general, we can say that in cases where we suspend a doctor’s authorization, it is to safeguard patient safety, says department director of the Norwegian Health Inspectorate, Anne Myhr, to news. The state administrator in Troms and Finnmark informs news that they, together with the Norwegian Health Authority, will carry out a local inspection of the radiology department at UNN during September. The substitute doctor who worked at UNN has also worked as a doctor at hospitals in the other Scandinavian countries. In Denmark, the man was temporarily stripped of his authorization in December, documents news has seen show. In Sweden, the supervisory authorities have launched an investigation into him. news has not been able to get an answer to whether the investigation has had consequences for the doctor’s ability to work in the country. Will look at the routines Sollid at UNN cannot answer how the doctor’s practice could have gone on for such a long time without being discovered. – We are looking at our internal systems, which should be able to capture this type of problem, he says. Acting director of UNN, Snorre Manskow Sollid. Photo: Simen Wingstad / news He says that UNN has routines to ensure that such things do not happen: When hiring, they make an assessment of qualifications, based on the doctor’s previous experience and self-reporting from the person concerned. When the doctor is in place at UNN, he is trained in routines and duties. In the beginning, the doctor is followed up, and the quality of the work they do is assessed. If the doctor fulfills the requirements set by UNN, they can enter the service. – The substitute doctor had worked with you for several years. Was he then past this control system? – We check in the form that if non-conforming things occur, it is reported in our non-conformance system, which we then follow up. – Are these routines something you are now looking at possibly tightening up? – We of course look at the routines, and that is also included as part of the follow-up that the Norwegian Health Authority does. Sollid points out that the substitute doctor who is now being investigated is experienced, and had been associated with UNN for many years, both as a hired substitute and a permanently attached substitute. – We have previously been confident that he carried out work according to the duties he has. But it is clear that there has been a change at some point. UNN does not have routine checks on how long doctors spend assessing each individual examination. Sollid points out that the time spent can also vary widely from survey to survey. Published 02.08.2024, at 10.44
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At least 1,000 samples are reviewed again – news Troms and Finnmark
