RE: Minnesota histology mistake
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.
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
>Rotherham General Hospital, Yorkshire
>From: Mike & Phyllis Thaxton [mailto:email@example.com]
>Sent: 29 January 2003 11:22
>To: Bryan.Watson@parkview.com; firstname.lastname@example.org
>Subject: Re: Minnesota histology mistake
> 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
Institute of Liver Studies
King's College Hospital
London SE5 9RS UK
+44 (0)20 - 7346 - 3125 telefax
+44 (0)20 - 7346 - 4627 office
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