Radiologists at Walter Reed National Military Medical Center's Naval Postgraduate Dental School in Bethesda, MD, failed to examine about 2,000 dental cone-beam CT (CBCT) scans during a seven-year period, resulting in at least one treatment delay, according to news reports.
A dental school radiologist failed to read about 1,300 CBCT scans of patients' faces and jaws between 2011 and 2016, setting off alarms that patients received subpar care and underwent unnecessary biopsies, according to an internal investigation by the Navy. In 2018, the investigation determined that an additional 500 scans were not read, leading to a seven-month surgical delay for one patient.
CBCT scans, which provide more details than conventional dental x-rays, allow clinicians to better locate tumors, infections, and other conditions. Typically, dentists, oral surgeons, or doctors request these scans, and Navy policy requires medical or oral maxillofacial radiologists to review and interpret them.
The backlog of unread scans came to light in 2016 after Laura Ike, PhD, DDS, began looking for a scan report for a patient who underwent a biopsy. Dr. Ike, an oral and maxillofacial pathologist at the dental school and a dentist, began looking through computer files and determined that the report she was looking for did not exist and about 1,300 other scans didn't have accompanying reports. She reported the situation to her superior and filed a patient safety report due to concerns that the person received inadequate care.
This triggered the Navy's internal investigation, which found the backlog was contributed to a shortage in staff, poor quality control, and technological problems. The investigation did not determine that it affected patient outcomes.
Unfortunately, there was another backlog. About 500 reports went unread between April 2018 and October 2018. A patient whose initial scan showed an abnormality requiring surgery received a scan, but she wasn't notified about a suspicious lump in her jaw until six months later.
Due to the backlog, Dr. Ike, who left the Navy in early 2019, believes about 100 patients may have received biopsies they didn't need and about 50 may have received inadequate or incomplete treatments.
Scans fell through the cracks after the dental school assigned an oral maxillofacial radiologist to read the scans but the doctor was diagnosed with an illness in 2012 and began working shorter hours and from home, according to the investigation. Dentists agreed to assist with reading the scans, but the arrangement never worked out, causing the backlog to grow.
In 2015, the school assigned another provider to take over the review of the scans. However, that person didn't receive certification for the task until 2016, which was around the same time that Dr. Ike noticed the backlog.
After her discovery. Dr. Ike provided the dental school with a file containing the approximately 1,300 names of patients whose scans went unread and requested that they be notified. However, citing privacy issues, the list was destroyed once the backlog was cleared.
A Navy medicine spokesperson said that the backlogs have been cleared. Other than the one patient whose treatment was delayed, no others were harmed, the spokesperson said.