Pathology Mistakes (Again) on Oprah and in the News

After watching and blogging about the first half of Oprah’s medical errors show that featured the story of Dennis Quaid’s kids, I finally got into the second half.

The first story is that of Molly (left), a woman who was told, after a mastectomy, that she indeed did NOT have breast cancer. Eight days after the operation, the doctor informed her that her anatomic pathology slides had been mixed up in the lab, leading to an incorrect diagnosis and many unnecessary tests (and the stress from thinking she had cancer). This happened at a medical facility that “was known for cancer care” per Molly.

Mixing up slides is what occurred in the case of Darrie Eason, a case that I blogged about here. I have spent time in pathology labs and there is no inherent reason why two patients’ slides should be mislabeled or mixed up – it’s a matter of bad processes, or at least processes that are not error proofed the way they should be.

The headline on Oprah’s page says “Shocking” medical mistakes (and the picture is an audience member who was clearly shocked). If errors like this had never occurred before, but might be shocking… but errors like this occur frequently enough that every pathology lab should be aware of the risks and should be putting process controls in place to prevent slides from being mixed up.

Processes and work need to be designed so that “batching” cannot occur. When slides are labeled in batches or tissue is worked on in batches (of multiple patients), there are risks of mix-ups occuring. Managers need to make sure employees don’t cut corners by batching (introducing the risk of mix-ups) and top leadership of a hospital lab or private pathology lab need to make sure managers aren’t implicitly or explicity emphasizing productivity and speed over quality.

Molly was relieved, but asked, “what about the lady whose slide was switched with me?” This type of error impacts two patients — the other woman had her cancer diagnosis (and treatment) delayed.

Oprah asked how the hospital discovered the error after the fact. After the surgery, they found no signs of cancer in her breast or her lymph nodes. It turned out that the lymph node slides had been switched. Now, before surgery, the doctors found breast cancer cells in Molly, but could not find a tumor (confirmed by multiple diagnostic tests, including CT and MRI). They were convinced Molly had a rare form of breast cancer where cells are found in the body, but there’s no tumor. When this “rare” cancer occurs, why not go and do another biopsy and re-test before rushing into surgery?

Oprah emphasized the dynamic where patients tend not to question doctors because “they’re smart people, they went to school for this.” The pathology errors (the physcial switching of the slide) is an operations error that has little to do with medical training. It’s the type of error that Toyota would probably be great at error proofing (not putting the wrong radio inside a certain car). Now maybe the medical training could play a role in the decisions being made (not re-testing for this supposedly “rare” disease, but the doctors and pathologists wouldn’t even be in that position if not for the operational error). Dr. Oz rightfully says the doctors “work hard, but they are humans.”

That’s why we need good processes and error proofing – we are human, we are not perfect.

Dr. Oz recommends asking for second opinions, asking for pathology reports and part of the specimen. This, unfortunately, adds cost and contributes to higher healthcare costs. So I’d prefer error proofing — this is how you can improve quality without increasing costs. Doing the same work twice gets quality but INCREASES costs.

Dr. Oz asks, “how could you switch the slides??” with a bit of incredulity.

Molly gives the answer I expected and already wrote about: the tech was working on two patients and cases at a time and my name got put on the slides of a lady who did have breast cancer.

To the pathology labs — no more batching, please!!!

In a related story, it seems like the same thing may have happened to another patient… a MAN. Yes, that’s right, a 28 year old man who was told, mistakenly, that he had breast cancer and underwent surgery.

Man suing hospital for unneeded mastectomy – UPI.com

Cruelest cut of all: 28-year-old man gets mastectomy, then finds out he didn’t have breast cancer

I saw him interviewed on TV, but there are very few details of his case online (probably because lawsuits are in the works.

As he relayed on TV, Scott Aprile was told “good news, you don’t have cancer.” AFTER the surgery. So he is suing and claims that the hospital “attacked” him, that the charges are inflammatory. Of course the charges are inflammatory. What do you bet that his slides were also mixed up because of this misguided “efficiency,” this batching???

I’ll try to follow up on his case.


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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 eBook 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 "Pathology Mistakes (Again) on Oprah and in the News"

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  1. Bruce B says:

    It's amazing how many 5 whys lead to large batch size (or lead through batch size anyway — there are usually some whys underneath large batch size). Take a note: single piece flow is good.

  2. Mark Graban
    Twitter:
    says:

    Here’s yet another case:

    http://www.nzherald.co.nz/lifestyle/news/article.cfm?c_id=6&objectid=11431997

    There were unsafe/bad practices in the lab:

    “In my view, SCL’s processes for handling late-delivery breast samples such as Mrs X’s included unsafe practices that directly contributed to Mrs X receiving biopsy results that did not belong to her.”

    And

    SCL’s internal investigation found that the error was likely to have occurred when the biopsy samples were removed from their transport containers and placed into a plastic cassette used to hold the biopsy sample while in the processing machine. This would have been during the “cut-up” process, in which tissue samples are prepared for analysis.

    A pathology registrar (trainee specialist) responsible for the transfer of samples into the cassettes told the commissioner’s office, “I have been over this in my mind many, many times and I do not know when in the process or how the error was made.”

    Mr Hill concluded that “it is difficult to identify at which point in the cut-up process the error occurred”.

    “… the error was the result of a number of unsafe policies and practices in place at the laboratory at the time. Accordingly, I consider that the ultimate responsibility for the error must fall on the laboratory itself.”

    Yes, things like this are systemic problems. It could relate to batching or other bad practices that make it too easy to mislabel or put the wrong specimen in the wrong cassette.

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