RE: Minnesota histology mistake

From:"Dawson, Glen"

You are SO right that it is scary.  I have to say something even more
frightening.  Bottom-Line: Nothing is Fail-safe.  A mixup like this will
lead to a larger pile of documentation and double checks for all of us
without a thought that more paperwork and procedures can only lead to more
stress-related accidents.  I'm sure by now all labs out there have gone to
great lengths to try to avoid mistakes like this but the knee-jerk reaction
remains: more paperwork, more redundant procedures, more double-checks,
more...  What if this boils down to a mistake caused by too much rushing due
to too little staffing.  If this is so, implementing more procedures
couldn't be more counter productive.
Glen Dawson  BS, HT &  QIHC (ASCP)
Lead IHC Technologist
Milwaukee, WI
ps  I believe the mistake that was made was tragic & totally unacceptable so
do not misconstru this email as me justifying what happened because it is
not justifiable, it is simply not absolutely avoidable.

-----Original Message-----
Sent: Wednesday, January 29, 2003 7:37 AM
Subject: 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

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
>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 
>To:  ;   
>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
>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 
>> knows.   
>MSN 8 helps eliminate e-mail viruses.   Get 2 months
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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