By February 13, 2008 3 Comments Read More →

Another Pathology Mishap

L.I. Hospital Scrutinized After Deaths of Patients – New York Times

It wasn’t the same laboratory this time, but it’s more than likely a similar root cause. I wrote before about pathology specimen labeling errors, how they’re preventable human error. Labs need to get away from batching multiple specimens (working with multiple patient specimens at the same time) and they need to stop blaming individuals when errors happen. We have to look at the system. We have to be proactive. We have to try to prevent errors from occurring.

You might recall an incident from last year, where a private NY pathology lab mixed up two patient specimens (“This Will Happen Again, Unless…“)

In this most recent case (at a hospital):

“Last spring, doctors at Mercy Medical Center on Long Island gave a patient the news she had feared: Cancer had been detected in her left breast. She was only in her 30s, but she decided to act swiftly because breast cancer ran in her family. On May 25, she had a double mastectomy. The next day, she died of complications from the surgery. As it turned out, the woman did not have cancer. According to the State Department of Health, the pathology report from the woman’s surgery had found no tumors in her breasts. The hospital’s lab had mixed up her test with another woman’s.

Why the woman died after the surgery is a altogether different story and there aren’t many details about that. The lab error was more clearly preventable.

Every pathology lab should be using Lean methods to identify “standardized work” methods that allow work to be done in a single-piece flow manner, reducing the opportunity for error. This should be done pro-actively, before an error occurs in your lab. I heard a lab manager say once, after being asked about error proofing that process, “But my people are careful.” I’m sure they were generally “careful” in Long Island also, but being careful is not enough.

How many times does something like this need to occur? For all of the truly complicated things in a hospital, this is NOT one of them. These processes are all pretty manual — put the right patient specimen onto the correct, properly labeled “cassette” or slide. These errors can be prevented.

In this article, a doctor who is speaking out very publicly about the problems at the hospital says:

“That mix-up was a simple procedure,” Dr. Anthony Colantonio said. “The simple thing of placing a label on a specimen container. That sort of mistake should not happen.” 

Thinking about this more, I might not be completely accurate in calling it a “pathology error.” It *is* possible that the specimen container was improperly labeled in the operating room, before it ever got to the lab.

Update: Here’ s an overview of the anatomic pathology and “histology” process steps, including a photo of the cassettes and slides that get labeled.

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Mark Graban's passion is creating a better, safer, more cost effective healthcare system for patients and better workplaces for all. Mark is a consultant, author, and speaker in the "Lean healthcare" methodology. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. His most recent project is an book titled Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also the VP of Improvement & Innovation Services for the technology company KaiNexus.

3 Comments on "Another Pathology Mishap"

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  1. Ian Furst says:

    This is a surgeon’s nightmare. I would suggest that the lab needs to look at their sigma value then work backwords to improve the process and lean it down not the other way around. The system has to be designed so that it is not just difficult to make an error, it has to be statistically impossible (short of sabotage). I think there is a general misconception in the community that highly reliable processes cannot be lean and that allow a low error rate improves efficiency.

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