Committee: Discipline
Decision Date: 17 Apr 2017
Summary:
On April 17, 2017, the Discipline Committee found that Dr. Zadra committed an act of professional misconduct in that he has engaged in conduct or an act or omission relevant to the practice of medicine that, having regard to all the circumstances, would reasonably be regarded by members as disgraceful, dishonourable or unprofessional.
Dr. Zadra is a staff urologist at the Royal Victoria Regional Health Centre (RVH) in Barrie, Ontario. Dr. Zadra received his certificate of registration authorizing independent practice in Ontario in 1984 and his specialist qualification in urology in 1988. Dr. Zadra has maintained his privileges at the RVH throughout the College investigation, described below, to the present.
In March 2014, the College received a complaint indicating that Dr. Zadra had been dictating operative reports that did not accurately reflect the work he had done. No patient harm was reported as a result of this practice.
RVH INVESTIGATION
RVH conducted a review of a portion of Dr. Zadra’s work, which revealed that Dr. Zadra inaccurately recorded the names of certain procedures that he performed.
Specifically, Dr. Zadra indicated that he performed a procedure named “cystometrogram” or “water cystometrogram”, while RVH had not had a functioning cystometrogram machine for at least several years. In addition, Dr. Zadra dictated that he performed a “urethrotomy” in three cases, when RVH did not have a pediatric urethrotome and this procedure should have been recorded as a “meatotomy”. Furthermore, in one case, Dr. Zadra dictated that he performed a procedure using a urethrotome under local anesthetic, which is considered to be an unusual practice as the urethrotome is only used in the operating room at RVH. Also, the operating room nursing staff indicated that Dr. Zadra’s dictation of the particular size of sutures he used while performing hernia repair on a patient were not in fact used according to the surgical count.
COLLEGE INVESTIGATION
The College retained an expert in urology and oncology, who opined that while Dr. Zadra’s practice did not expose patients to harm, there were some planned or proposed procedures that could have exposed patients to potential harm if they had been carried out.
In addition, similarly to the results of the RVH investigation, the expert reported concerns with Dr. Zadra’s record keeping, documentation and description of the procedures performed, including the “semantics and labeling of the procedures actually performed.”
The expert noted that for five patients, Dr. Zadra dictated that he performed a “water cystomerogram”, while he later admitted in his interview with the expert that the Ambulatory Care Unit at RVH did not have a functioning cystometrogram machine. It was noted, that in one case of a circumcision of an 8-year old boy, Dr. Zadra failed to dictate issues that should have been documented, such as pre- and post-operative urine stream. In another case, Dr. Zadra dictated a procedure of “hernia repair with multiple 2-0 and 3-0 Vicryl sutures” that did not correspond to the operating room nurses’ suture count. The discrepancy was that 3-0 sutures were in fact used. In two other cases, Dr. Zadra dictated that he performed a “urethrotomy”, when he should have dictated it as a “meatotomy”. It was also revealed that in two cases, Dr. Zadra amended his dictated note to different procedures than he had initially recorded.
The expert further opined that in a number of patient charts, the description of the procedures actually performed was inaccurate, leading to inaccurate and/or questionable claims submissions to OHIP. Although the amounts were small, a number of fee codes were billed in error due to the inaccurate description of procedures performed.
For example, for several patients, Dr. Zadra had billed the OHIP code, which covers “pelvis limited study other than pregnancy” done by ultra-sound and was paid at $21.95. In his interview with the expert, Dr. Zadra stated that in fact he had carried out a “post-void residual urine measurement”, which should have been billed at the rate of $12.70. Another example was billing an OHIP Code for what was dictated as a “water cystometrogram”, when the procedure was not in fact performed on several patients.
On April 17, 2017, the Committee ordered and directed on the matter of penalty and costs that:
- The Registrar suspend Dr. Zadra’s certificate of registration for a period of three (3) months;
- The Registrar impose the following terms, conditions and limitations on Dr. Zadra’s Certificate of Registration:
Instruction in medical ethics
(i) At his own expense and within twelve (12) months of the date of this Order, Dr. Zadra shall participate in and successfully complete individualized instruction in medical ethics satisfactory to the College, with an instructor selected by the College. The instructor shall provide a summative report to the College including his or her conclusion about whether the instruction was completed successfully by Dr. Zadra.
Medical record-keeping
(ii) At his own expense and within twelve (12) months of the date of this Order, Dr. Zadra shall participate in and successfully complete a record-keeping course acceptable to the College, and provide proof of completion thereof to the College;
Clinical Supervision
(iii) At his own expense and within thirty (30) days of this Order, Dr. Zadra shall retain a Clinical Supervisor approved by the College, who will sign an undertaking in the form attached to this Order as Schedule “A”;
(iv) For a period of six (6) months commencing from the date Dr. Zadra resumes practice following the suspension of his certificate of registration described in paragraph 2, Dr. Zadra may practise only under the supervision of the Clinical Supervisor (“Clinical Supervision”);
(v) Clinical Supervision of Dr. Zadra’s practice shall contain the following elements:
(a) Review, on a monthly basis, operating room dictations and notes in a minimum of twenty-five (25) patient charts, to be selected at the sole discretion of the Clinical Supervisor, along with the corresponding OHIP claims submissions;
(b) Discuss with Dr. Zadra any concerns the Clinical Supervisor may have arising from the chart reviews;
(c) make recommendations to Dr. Zadra for practice improvements and ongoing professional development, and inquire into Dr. Zadra’s compliance with the recommendations;
(d) the Clinical Supervisor will keep a log of all patient charts reviewed along with patient identifiers; and
(e) the Clinical Supervisor will provide reports to the College on a bi-monthly basis for the six (6) month period of practice monitoring, or more frequently if the Clinical Supervisor has concerns about Dr. Zadra’s standard of practice or conduct.
(vi) Throughout the period of Clinical Supervision, Dr. Zadra shall abide by the recommendations of the Clinical Supervisor;
(vii) If a clinical supervisor who has given an undertaking as set out in Schedule “A” to this Order is unable or unwilling to continue to fulfill its terms, Dr. Zadra shall, within twenty (20) days of receiving notice of same, obtain an executed undertaking in the same form from a person who is acceptable to the College and ensure that it is delivered to the College within that time;
(viii) If Dr. Zadra is unable to obtain a clinical supervisor in accordance with paragraph (vii) of this Order, he shall cease to practice until such time as he has done so;
(ix) Dr. Zadra shall consent to the disclosure by his Clinical Supervisor to the College, and by the College to his Clinical Supervisor, of all information the Clinical Supervisor or the College deems necessary or desirable in order to fulfill the Clinical Supervisor’s undertaking and Dr. Zadra’s compliance with this Order;
(x) Dr. Zadra shall inform the College of each and every location where he practices including but not limited to hospital, clinics and offices, in any jurisdiction (collectively his “Practice Location(s)), within fifteen (15) days of this order and shall inform the College of any new Practice Locations within fifteen (15) days of commencing practice at that location, for the purposes of monitoring his compliance with this Order;
(xi) Dr. Zadra shall submit to, and not interfere with, unannounced inspections of his Practice Locations(s) and patient records by a College representative, for the purposes of monitoring his compliance with this Order;
(xii) Dr. Zadra shall consent to the monitoring of his OHIP billings and cooperate with inspections of his practice, his patient charts and his OHIP billings by his Clinical Supervisor and College representatives for the purpose of monitoring his compliance with the terms of this Order;
(xiii) Dr. Zadra shall provide consent to the College to make appropriate enquiries of OHIP, for a period of one (1) year after he resumes practice following the suspension of his certificate of registration described in paragraph 2, for the purpose of monitoring his compliance with the terms of this Order; and
(xiv) Dr. Zadra shall be responsible for any and all costs associated with implementing this Order.
- Dr. Zadra attend before the Committee to be reprimanded;
- Dr. Zadra pay costs to the College in the amount of $5,000.00 within thirty (30) days of the date this Order becomes final.