RE: Minnesota histology mistake

From:

Jackie.O'Connor@abbott.com

Does anyone know how they finally determined it was a biopsy mixup, aside from the micros not matching? Was surgery performed on the appropriate patient finally? I've heard "strange but true" horror stories like this one for years.

Jackie O'

Alex Knisely <alex.knisely@kcl.ac.uk>

01/29/2003 06:56 AM

To: "Marshall Terry Dr, Consultant Histopathologist" <Terry.Marshall@rothgen.nhs.uk>, histonet@pathology.swmed.edu
cc:
Subject: 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.

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
>terry.marshall@rothgen.nhs.uk
>
>-----Original Message-----
>From: Mike & Phyllis Thaxton [mailto:thaxfax@msn.com]
>Sent: 29 January 2003 11:22
>To: Bryan.Watson@parkview.com; histonet@pathology.swmed.edu
>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.
>
>Phyllis
>
>
>
>
>
>
>>From: Bryan Watson <Bryan.Watson@parkview.com>
>>To: histonet@pathology.swmed.edu
>>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.
>>Thanks,
>>Bryan
>
>
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Alex Knisely, MD
Consultant Histopathologist

alex.knisely@kcl.ac.uk

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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