Minnesota mistake

From:Fearn Tony

Have been reading the original posting and subsequent replies about the
unfortunate incident of the mix-up in Minnesota. A similar incident occurred
in the U.K. in March 1999, again it was a breast biopsy case. As soon as we
knew about it through the Press, our Head of Department called a meeting of
all the Histology staff from trainee through assistants, biomedical
scientists and clerical staff  to consultant histopathologists. This was to
review our own departmental checking and fail-safe systems already in place.
It was a brain-storming session in which we listed all the procedures from
the tissue arriving in the laboratory to the authorised report being put
into the mail box. The bullet points were written down, put in order later
on and typed up as a revised Standard Operating Procedure which was then
re-checked by all grades of staff. It was written in an 'idiot guide'
format, in that all the stages of the process were itemised in a clear,
easy-to-follow way however insignificant they seemed to be.. The main
procedure headings were:-

Specimen reception
Booking in
Setting out for cut-up
Cut-up itself
Tissue processing
Work sheet/block check
Microtomy including primary slide labelling
Block/slide check post staining and coverslipping
Final labelling with the paper computer-written labels
Special stains and IHC requesting
Diagnosis and reporting by the histopathologists
Authorisation and despatch of reports.

There have been many e-mails that just advised on one or two points but I
think perhaps, as a Department, going over all procedures, as well as
reviewing the obvious ones intimately related to the mistake, will re-affirm
your collective belief that at least the fail-safes you have in place are ok
and sound. How we can deal with human error as shown in Gary Gill's recent
e-mail to Histonet is a whole different ball game.  

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