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 as in any case where there is human action involved, there will always be the possibility of human error.
One way physicians and hospitals can truly prevent these types of errors (and subsequent adverse outcomes) from happening again is to implement the know error® specimen security system, introduced in 2009 by Diagnostic ID, LCC. The know error® system provides DNA confirmation of a positive biopsy result. The process involves sending tissue from the positive biopsy as well as a tissue sample taken from the patient via a cheek swab to an independent forensics lab. The lab then matches the biopsy tissue sample with the reference sample from the patient. The process confirms the cancerous tissue sample belongs to the patient. If there is not a match, as would have been the case here, the process is halted and the error is detected prior to any adverse patient outcome.
To learn more about the know error® specimen security system, visit www.knowerror.com.
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