RE: Minnesota histology mistake

From:Tony Henwood

RE: Minnesota histology mistake

Hi all,
I'm not sure what the issue in Minnesota was but your cut up (or grossing) practices seem very responsible to me. All we can do is manage to reduce the risk of a specimen mix-up. You can't prevent human error or should I say Bad luck. We can only reduce the chance of it happening.

But then I am not a Lawyer!!

I know we all try our best. That is all anyone should expect.

Tony Henwood JP, BappSc, GradDipSysAnalys, CT(ASC)
Laboratory Manager
The Children's Hospital at  Westmead,
Locked Bag 4001, Westmead, 2145, AUSTRALIA.
Tel: (02) 9845 3306
Fax: (02) 9845 3318

-----Original Message-----
From: Mike & Phyllis Thaxton []
Sent: Wednesday, 29 January 2003 22:22
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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