A Newsday article published on November 11, 2009, revealed another biopsy switching error that resulted in an unnecessary lumpectomy and removal of lymph nodes. In this case, the patient was 35 year-old Janelle Trenchfield who has filed a negligence lawsuit against the medical facility where her surgery was performed.
As with cases previously covered by this blog, Trenchfield didn't find out she was cancer-free until AFTER the surgery when routine post surgical tests showed the tissue samples from the surgery were negative for cancer. Her biopsy lab results had been switched after a label with her name was attached to another patient's tissue samples. Additionally, in this case, the error was also attributed to "human error and procedural issues." A hospital spokesman claimed, "All procedures for the handling and labeling of tissue samples were immediately revised."
In each of the cases we have covered, revising or improving procedures appears to be the common solution proposed to solve these patient misidentification errors. While procedural improvements can serve to reduce the number of errors that occur, a study* published in the Journal of Urology suggested that these types of errors likely cannot be eliminated through procedural improvements alone. Additionally, the study proposed these types of errors may be entirely eliminated with the use of DNA matching prior to any treatment taking place.
The know error® specimen security system, introduced in 2009 by Diagnostic ID, LLC, provides a solution to finding biopsy identity switches by incorporating both an error reduction system and DNA fingerprinting technology. The know error® system employs patient-specific bar-coding for the purpose of reducing errors and forensic DNA fingerprinting for the purpose of preventing errors that may result in an adverse patient outcome.
The know error® system uncovers patient identification errors by matching tissue from a positive biopsy result to a reference sample taken from the patient via a simple cheek swab to confirm that the tissue belongs to the patient. By performing DNA matching PRIOR to treatment, the know error® specimen security system assures that biopsy switching errors will be detected prior to any unnecessary surgery or treatment.
For more information about the know error® specimen security system with unique patient code and DNA confirmation, please visit our web site at www.knowerror.com.
* Eric J. Suba, John D. Pfeifer and Stephen S. Raab Patient Identification Error Among Prostate Needle Core Biopsy Specimens--Are We Ready for a DNA Time-Out? Journal of Urology Vol. 178, 1245-1248, October 2007
You can read some of the sad history of the pattern of preventable mistakes that keep occurring in medical laboratories:
http://www.leanblog.org/2009/11/yet-again-hospital-lab-mixes-up-patient.html
One mistake is too many. We can't rely on people being careful, we need good systems and process that help prevent errors like this from happening again.