This is really discouraging to see yet another serious specimen labeling mishap in a pathology department that's led to the good news / bad news situation that we've read about before:
- Good News: You don't have cancer after all
- Bad News: We performed an unnecessary surgery because we made a procedural error
From the recent news, in Long Island, as we've seen before:
A biopsy at Winthrop-University Hospital in Mineola had confirmed the diagnosis, and so in June, the anguished Freeport woman had surgery to remove a lump and lymph nodes – only to find out days later that she hadn't had cancer at all.
The biopsy results, she learned, had been mixed up. A label with her name had been put on the tissue samples of a different patient.
I've written about this issue previously:
Being Careful Isn't Enough, Particularly in Pathology
There, I told the story of a hospital lab I visited where the Director basically relied on her “careful” people to avoid making a similar mistake. The technologists, in the case I saw, were clearly “batching” their work – a misguided attempt at very minimal productivity improvement that puts patients in jeopardy. Good, safe practice is to have only one patient specimen active in the workspace at a given time.
With batching, they were labeling multiple sets of slides at once, leaving three different patient sets in the field of work, creating the opportunity for error if the technologist grabbed the wrong slide to place a specimen on. This saves the technologist the minor effort of setting the pen down and picking it up (if they're labeling manually, as often happens).
I asked a former colleague who has done more work in Anatomic Pathology and he confirmed that the time saved from batching is extremely minimal. I'd say it's basically a misguided bad habit, this batching. Laboratory managers need to be aware of the risk of batching and they need to oversee the process and the people to make sure batching doesn't take place — ever.
This Will Happen Again, Unless…
A sad case from 2007 where a woman, Darrie Eason, had an unnecessary mastectomy and “batching” was blamed — an individual was fired… does that really fix the process? As McDreamy asked recently on Grey's Anatomy, who is responsible for the system? Leadership.
Another Pathology Mishap
As I predicted, here was another Long Island mixup, from 2008. So what the heck is wrong with Long Island that they are having so many errors of this kind??
Pathology Mistakes (Again) on Oprah and in the News
Earlier this year, Oprah had a woman on her show who was harmed by a similar situation.
So back to the most recent case, it sounds very familiar:
Winthrop spokesman John Broder said the hospital has not been officially served with the lawsuit but acknowledges the mix-up.
“After a thorough investigation, this was determined to be as a result of human error and procedural issues,” Broder said. “All procedures for the handling and labeling of tissue samples were immediately revised.”
Broder did not provide any information about personnel involved in the mix-up or specifics about changes in procedure.
So it sounds like the hospital acknowledges, viz a vis the change in the process, that the old process was bad. I'm guessing, but it wouldn't be unreasonable to assume that batching was involved.
We can't just shrug our shoulders and say “oh well, human error.” That runs the risk of being an excuse. We have to design systems and processes that make it harder for errors to be created.
I partially agree with this expert statement:
Arthur Levin, director of the nonprofit Center for Medical Consumers in Manhattan, said that tissue-sample mistakes point to a system breakdown.
“These kinds of mistakes are human errors that can only be prevented by having systems in place to prevent them,” Levin said. “You have to develop a tried-and-true system that has double checks.”
I agree with Levin that this is a systemic problem. I'd rather focus on prevention and error proofing (through good processes, including NOT batching) than relying on extra inspections or double checks.
So what do we do as patients?
I normally try to not be an alarmist, but it appears that the Anatomic Pathology profession is demonstrating an ability to fix their processes and learn from the mistakes of others. Until proven otherwise, my policy would be the following if it was myself or a loved one who was given a positive cancer diagnosis:
- I'd insist on a second opinion and second confirming lab test (ugh, this might require a second biopsy or out of pocket costs???)
- Or I'd demand to go to the lab where my testing was done to investigate the process myself. A manufacturer can go inspect a supplier's process, why can't a patient do the same as a customer???
What are your reactions to this, as a patient or as a laboratory?
Hat tip to the “Dead By Mistake” blog for highlighting this case…
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