On September 5, 2009, a story out of Australia discussed the case of a Melbourne woman who went in for laparoscopic procedure in December of 2008 to investigate a uterine cyst. Pathology reports showed the diagnosis of stage three uterine cancer, and she was advised to have a radical hysterectomy.
To further exacerbate the diagnosis, the woman's experience with the "overstretched" medical system was extremely challenging. It took more than a month for her to get her lab results, even though it only took two days for the pathology lab to process her sample. Furthermore, she was notified over the phone by a nurse who offered no additional information other than the fact that she had cancer. The nurse advised her that she would need to wait a couple of weeks for a call back from the doctor. In February 2009, a month after her diagnosis and after additional tests revealed the cancer had not spread, she was advised to have a radical hysterectomy. She had planned to have more children and asked if her ovaries could be saved but was informed that everything would need to be removed.
She had her surgery in March 2009 and about two weeks later she received a call from a nurse informing her "...there was good news..." and that she didn't have cancer. Again, with no additional information, she was told that someone would call to explain.
A hospital investigation revealed her sample had been contaminated with tissue from a patient who had cancer. The hospital apologized but did not offer further explanation about what happened in the lab, why the woman was notified over the phone, or if another patient was affected by this misdiagnosis. The hospital insists it has reviewed its procedures to prevent this from happening again, but without establishing specimen provenance, there is no way to fully ensure this.
With the complexity of the biopsy evaluation process, physicians and patients need an effective way to establish specimen provenance of biopsy tissue samples. Through the use of DNA Specimen Provenance Assignment (DSPA) and bar code technology, the know error® system brings new levels of safety and accuracy to the biopsy evaluation process. This innovative system virtually eliminates the possibililty of adverse patient outcomes due to Specimen Provenance Complications (SPC). By performing DSPA prior to treatment, the know error® system assures that SPCs will be detected prior to any unnecessary surgeries or treatment plans.
The know error® system dramatically reduces the incidence of SPCs enhancing patient safety and diagnostic accuracy. For more information about the know error® system, visit our website at www.knowerror.com.
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