RE: Minnesota histology mistake

From:Alex Knisely

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
>MSN 8 helps eliminate e-mail viruses. Get 2 months FREE*.  
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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