Nearly 2,000 dental CT scans remained unread
for a number of years at a U.S. navy hospital
for a number of years at a U.S. navy hospital
Nearly 2,000 unread CT scans discovered at U.S. Navy hospital
November 26, 2019
by John R. Fischer, Senior Reporter
Close to 2,000 CT scans remained unread for a number of years at a Navy military hospital.
Walter Reed National Military Medical Center pointed to faulty processes, oversights by physicians, technical difficulties and the overwork of a radiologist as reasons for why 1,300 cone beam CT scans at the Navy’s postgraduate dental school remained unread between 2011 and 2016, along with a second backlog of 500 more discovered in 2018.
An internal investigation found at least one documented case of delay in treatment as a result of the missed scans, with one physician fearing that hundreds more may be at risk as a result.
"The investigation determined that the CBCT backlog did not result in adverse outcomes for patients and made several recommendations to improve procedures," Ed Gulick, spokesman for Navy Medicine, told the Wall Street Journal. "The backlog of CBCT scans has been cleared, and the investigation's recommendations are currently being implemented by the Naval Postgraduate Dental School."
The scans depicted the faces and jaws of patients, with the first 1,300 found by Dr. Laura Ike, a former Navy oral pathologist, in 2016. Ike came across the scans while searching for the results of a patient’s CBCT scan. When told that a “computer glitch” might be the reason why she could not find the scan, she searched in the broader system, where she came across the unread images.
"I kept getting biopsies on patients who had had CT scans but there was no radiology report," Dr. Ike, who left the Navy this year to work in private practice, told WSJ. "Some biopsies were done that might not have been done had there been a scan provided."
Upon reporting the matter, Ike was berated by her superiors for viewing data of patients not under her care, she said. An internal probe uncovered a number of problems behind the backlog, including one pertaining to a radiologist who worked from home for months at one point while undergoing treatment for cancer. Technical difficulties and “severe malaise” prevented the individual, whose name was redacted from the report, from keeping up with the workload. Other radiologists faced challenges in gaining credentials and computer resources to read the scans.
CBCT scans enable clinicians to view 3D images of a tooth’s roots in a complex root canal, as well as assess lesions or potential tumors in the jaw to determine if biopsies or further treatments are necessary. Dentists or physicians often review these scans, which require no further readings in civilian settings. Military regulations, however, require that any administered by the navy be read by a radiologist, according to Gulick.
The navy reported that no misuse or harmful intent was found, and no punishments were levied against anyone. Patients were not informed their scans were not read, with the navy saying it intended to reach out if areas of concern were found but that none were uncovered to follow up. The scans were read and the backlog was deleted.
Following this incident, another 500 cases were discovered in 2018. The navy admitted that one patient’s pathology that went missing for seven months did delay needed treatment, but found no indications that any cases became worse. It disagrees with the notion that patients were harmed.
A colleague of Ike’s, whose name was also redacted, called the investigation “a farce,” saying the unread reports led to “hundreds of cases” involving potentially dangerous oral lesions going untreated.
Though Ike was told that patients would be made aware of the situation, no record of notification was provided, she said. In addition, the list of names for the original 1,300 patients was deleted due to “privacy concerns” by an employee whose name was redacted from the investigation. The list is impossible to reconstruct, according to investigators.
The scans " were properly reviewed later and the backlog cleared with the conclusion that there was no harm to patients," said Gulick.
Gulick says the Navy is implementing recommendations made by investigators to prevent similar incidents in the future.
A request for comment to Walter Reed National Military Medical Center was directed to the Department of the Navy's Bureau of Medicine and Surgery, BUMED. No response has been offered at this time.
Walter Reed National Military Medical Center pointed to faulty processes, oversights by physicians, technical difficulties and the overwork of a radiologist as reasons for why 1,300 cone beam CT scans at the Navy’s postgraduate dental school remained unread between 2011 and 2016, along with a second backlog of 500 more discovered in 2018.
An internal investigation found at least one documented case of delay in treatment as a result of the missed scans, with one physician fearing that hundreds more may be at risk as a result.
"The investigation determined that the CBCT backlog did not result in adverse outcomes for patients and made several recommendations to improve procedures," Ed Gulick, spokesman for Navy Medicine, told the Wall Street Journal. "The backlog of CBCT scans has been cleared, and the investigation's recommendations are currently being implemented by the Naval Postgraduate Dental School."
The scans depicted the faces and jaws of patients, with the first 1,300 found by Dr. Laura Ike, a former Navy oral pathologist, in 2016. Ike came across the scans while searching for the results of a patient’s CBCT scan. When told that a “computer glitch” might be the reason why she could not find the scan, she searched in the broader system, where she came across the unread images.
"I kept getting biopsies on patients who had had CT scans but there was no radiology report," Dr. Ike, who left the Navy this year to work in private practice, told WSJ. "Some biopsies were done that might not have been done had there been a scan provided."
Upon reporting the matter, Ike was berated by her superiors for viewing data of patients not under her care, she said. An internal probe uncovered a number of problems behind the backlog, including one pertaining to a radiologist who worked from home for months at one point while undergoing treatment for cancer. Technical difficulties and “severe malaise” prevented the individual, whose name was redacted from the report, from keeping up with the workload. Other radiologists faced challenges in gaining credentials and computer resources to read the scans.
CBCT scans enable clinicians to view 3D images of a tooth’s roots in a complex root canal, as well as assess lesions or potential tumors in the jaw to determine if biopsies or further treatments are necessary. Dentists or physicians often review these scans, which require no further readings in civilian settings. Military regulations, however, require that any administered by the navy be read by a radiologist, according to Gulick.
The navy reported that no misuse or harmful intent was found, and no punishments were levied against anyone. Patients were not informed their scans were not read, with the navy saying it intended to reach out if areas of concern were found but that none were uncovered to follow up. The scans were read and the backlog was deleted.
Following this incident, another 500 cases were discovered in 2018. The navy admitted that one patient’s pathology that went missing for seven months did delay needed treatment, but found no indications that any cases became worse. It disagrees with the notion that patients were harmed.
A colleague of Ike’s, whose name was also redacted, called the investigation “a farce,” saying the unread reports led to “hundreds of cases” involving potentially dangerous oral lesions going untreated.
Though Ike was told that patients would be made aware of the situation, no record of notification was provided, she said. In addition, the list of names for the original 1,300 patients was deleted due to “privacy concerns” by an employee whose name was redacted from the investigation. The list is impossible to reconstruct, according to investigators.
The scans " were properly reviewed later and the backlog cleared with the conclusion that there was no harm to patients," said Gulick.
Gulick says the Navy is implementing recommendations made by investigators to prevent similar incidents in the future.
A request for comment to Walter Reed National Military Medical Center was directed to the Department of the Navy's Bureau of Medicine and Surgery, BUMED. No response has been offered at this time.