Walter Reed Failed to Examine Almost 2,000 CT Scans
Nearly 2,000 radiology scans went unread for several years at Walter Reed National Military Medical Center, leading to at least one documented delay in treatment and one physician fearing hundreds more, an internal investigation found.
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Nearly 2,000 radiology scans went unread for several years at Walter Reed National Military Medical Center, leading to at least one documented delay in treatment and one physician fearing hundreds more, according to an internal investigation.
The queue of unread scans had gone unnoticed for years until Laura Ike, a former Navy oral pathologist, uncovered the problem in 2016, when she couldn’t find the results of a patient’s CBCT scan, the investigation found. She was told it was likely a “computer glitch.” She worried that other scans might also be missing, however, so she checked the broader system and found 1,300 scans from 2011-2016 had gone unread.
“I kept getting biopsies on patients who had had CT scans but there was no radiology report,” said Dr. Ike, who left the Navy this year for private practice. “Some biopsies were done that might not have been done had there been a scan provided.”
Dr. Ike was chastised by her superiors for accessing data of patients who weren’t hers, according to testimony in the investigation.
The internal probe found a series of problems had led to the backlog. One radiologist, whose name was redacted from the investigation and who was assigned to read the scans, underwent cancer treatment during some of this period. For months, the radiologist was working from home where technical problems and “severe malaise” prevented the individual from keeping up with the workload. Others radiologists, meanwhile, struggled to get credentials and computer resources to read the scans.
After the backlog was discovered and addressed, Dr. Ike’s superior told her the patients would be notified, according to testimony given to investigators, though she said that the Navy didn’t provide a record of the notifications.
An employee, whose name was redacted from the investigation findings, deleted the list of the original 1,300 patients whose scans were delayed, citing privacy concerns for those patients. The list is impossible to recreate, investigators said.
Mr. Gulick, the Navy spokesman, said that the scans “ were properly reviewed later and the backlog cleared with the conclusion that there was no harm to patients.”
