RE: Minnesota histology mistake


This particular situation . . . both biopsies were on the same tray (specimen containers, blocks, slides all labeled correctly) and a pathologist picked up one set of slides and the other set of paperwork and never compared the name or number (apparantly the name was on the slide as well).  This is based on the news reported here, in Minnesota.  However, we all know how easily this COULD have been a labeling error and rested on the shoulders of a histotech instead of a pathologist.  We too are having meeting after meeting to discuss the issue and ways to "ensure" that it doesn't happen again.  The hospital in question is having all slides read by two pathologists and have instituted a color coding system as well (not sure about the details).  I think this would be the perfect opportunity for SOMEONE (not in Minnesota since many hospitals and staff here are fearful of lawsuits) to speak out about the shortages of histotechs, the low pay and of course the degree to which we are overworked.  Mistakes increase when everyone is tired and stressed, techs and pathologists alike.  Okay, just my two cents.  I better sign off before I get myself into too much trouble:-)  Have a great day.  Jen

>>> Alex Knisely <> 01/29/03 06:56AM >>>
If I remember correctly: Bilateral mastectomy undertaken unnecessarily, on
the basis of findings in a core needle biopsy specimen from another woman.

Same biopsy suite, with switched pots?

But certainly the same histopathology facility, with the questions then being:

Switched cassettes at time of transfer from pot to cassette? Switched
blocks at time of embedding? Switched pencil-labelled glass slides at time
of section pick-up? Switched paper labels on slides? Switched patient ID
on dictated results?

All potential sources of error.

Alex K

At 12:21 29/01/03 +0000, Marshall Terry Dr, Consultant Histopathologist wrote:
>Could someone explain what "this breast mix-up in Minnesota" is about?
>Terry L Marshall B.A.(Law), M.B.Ch.B., F.R.C.Path
>Consultant Histopathologist
>Rotherham General Hospital, Yorkshire
>-----Original Message-----
>From: Mike & Phyllis Thaxton []
>Sent: 29 January 2003 11:22
>Subject: Re: Minnesota histology mistake
>Hi Bryan,
> This has become a HUGE issue at our hospital as well. Already, we never
>assign consecutive accession numbers. We always put the patient's initials
>on the side of the blocks. We never place more than one breast case on a
>tray os surgicals. Now the pathologists have asked, what else can we do to
>insure this could never happen to us. I am very much open for more
>suggestions as well.
>>From: Bryan Watson <>
>>Subject: Minnesota histology mistake
>>Date: Tue, 28 Jan 2003 16:11:06 -0500
>>Has anyone changed their protocol for doing things since this breast
>>mixup in Minnesota? If so could you explain how you have changed things
>>to insure these mistakes never happen.
>>We have suddenly had a lot of people coming in and asking how we could
>>improve things so this does not happen here. We like to think that it
>>could not happen with the way we do things, but I guess one never
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Alex Knisely, MD
Consultant Histopathologist

Institute of Liver Studies
King's College Hospital
Denmark Hill
London SE5 9RS UK

+44 (0)20 - 7346 - 3125 telefax
+44 (0)20 - 7346 - 4627 office

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