Just days after the disclosure that nearly 4,000 echocardiograms performed at Harlem Hospital Center were never read by a physician, a team of a dozen doctors have gone through 1,500 them, all of which have thus far been found to be normal.
The total missed over the last three years equates to nearly two years worth of tests that were never read--Harlem Hospital routinely does about 2,500 a year. The hospital told the New York Times that the problem was a result of a system in which technicians flagged any tests that looked abnormal so that physicians would look first at them. The problem? If the test wasn't flagged, it apparently was never read.
New York City Health and Hospitals Corporation released a statement from its president, Alan Aviles, that said that the mistake was "inexcusable and may have placed patients at risk." As a result, Aviles fired the clinical director of the hospital's department of medicine, Alfred Ashford, MD, and demoted the medical director, Glendon Henry, to attending physician. He reported both physicians to state authorities for further investigation and didn't rule out further disciplinary action within the hospital.
An immediate change to the policy now requires that all echocardiograms be given to physicians within two working days. There will also be monthly reviews to determine how many tests are unread.
Such incidences are rare, but not unknown. In 2002, Biotechniques reported on unread HIV tests that were rescued from a freezer; and back in 1980 there was a JAMA report on unread TB tests.
For more information:
- read this New York Times article