Recently in mislabeled biopsy Category

The know error® system for breast biopsies will be participating at the Society of Breast Imaging's (SBI) next course -- Practical Breast MRI: Case Based Review." The course takes place January 28 - 29, 2012 at the Hilton Bonnet Creek Hotel in Orlando, FL. Look for our tabletop display in the registration area.

Know Error develops and markets the know error® system for breast biopsies which utilizes bar coding, forensic principles and DNA matching to confirm that the biopsy samples being evaluated belong to the patient being diagnosed. Available for a diverse range of tissue types, including breast, the know error® system brings new levels of patient safety and diagnostic accuracy to the biopsy evaluation process.

Since the company's launch in 2009, hundreds of physicians in a variety of specialties have incorporated the know error® system as a standard for their patient care. To learn more about the know error® system for breast biopsies, visit our website www.knowerror.com.

The know error® system is exhibiting at RSNA 2011 -- the 97th Scientific Assembly and Annual Meeting of the Radiological Society of North America. The meeting is being held November 27th - December 2nd at McCormick Place in Chicago. Come see us at Booth 1006 in Hall D (Lakeside Center).

In addition to participating in the meeting, Know Error is a proud supporter of the RSNA Exhibitor Circle Program which supports and provides funding for the RSNA's Research and Education Foundation. The Foundation's mission is "to improve patient care by supporting research and education in radiology and related scientific disciplines through funding grants and awards to individuals and institutions that will advance radiologic research, education and practice."

Know Error develops and markets the know error® system which utilizes bar coding, forensic principles and DNA matching to confirm that the biopsy samples being evaluated belong to the patient being diagnosed. Available for a diverse range of tissue types, the know error® system brings new levels of patient safety and diagnostic accuracy to the biopsy evaluation process.

Since the company's launch in 2009, hundreds of physicians in a variety of specialties, including radiology, have incorporated the know error® system as a standard for their patient care. To learn more about the know error® system, visit our website www.knowerror.com.

Know Error is sponsoring the 2nd Annual Connecticut Challenge Survivorship Summit: "Bringing Together Leaders in Cancer Survivorship." This annual symposium will be held November 15, 2011 at the New Haven Lawn Club in New Haven, CT. The event is featuring speakers from world renowned cancer centers, including Memorial Sloan Kettering Cancer Center and the Abramson Cancer Center of the University of Pennsylvania. Kenneth Miller, MD, Director of the Lance Armstrong Foundation Adult Survivorship Program at Dana-Farber Cancer Institute and Instructor in Medicine at Harvard Medical School, will wrap up the program with a presentation titled: "Buy-in and Pushback: How survivorship fits into the system." Click here to learn more about this meeting.

The mission of the Connecticut Challenge is "to empower cancer survivors to live healthier, happier and longer lives."  According to its website, the Connecticut Challenge raised more than $1.4 million in 2010 with 86 cents of every dollar going towards program services and grants.

Know Error develops and markets the know error® system which utilizes bar coding, forensic principles and DNA matching to confirm that the biopsy samples being evaluated belong to the patient being diagnosed. Available for a diverse range of tissue types, including prostate and breast, the know error® system brings new levels of patient safety and diagnostic accuracy to the biopsy evaluation process.

Since the company's launch in 2009, hundreds of physicians in a variety of specialties have incorporated the know error® system as a standard for their patient care. To learn more about the know error® system, visit our website www.knowerror.com.

The know error® system for prostate biopsies is exhibiting at a meeting of the Chicago Urological Society that will focus on prostate cancer. The meeting is being held November 9th, 2011 at the University Club of Chicago. Among other medical experts and urologists speaking at the event, the keynote speaker will be Alan Partin, MD, PhD, Urologist-in-Chief, Department of Urology at Johns Hopkins Hospital. Click here for more information on this meeting.

Know Error develops and markets the know error® system for prostate biopsies which utilizes bar coding, forensic principles and DNA matching to confirm that the biopsy samples being evaluated belong to the patient being diagnosed. Available for a diverse range of tissue types, including prostate, the know error® system brings new levels of patient safety and diagnostic accuracy to the biopsy evaluation process.

Since the company's launch in 2009, hundreds of physicians in a variety of specialties, including urology, have incorporated the know error® system as a standard for their patient care. To learn more about the know error® system for prostate biopsies, visit our website www.knowerror.com.

Know Error is hosting a User's Group Luncheon Meeting prior to the Large Urology Group Practice Association's 2011 Annual Meeting. The luncheon is being held on November 3rd, from 11:00 am - 2:00 pm, at the Drake Hotel in Chicago. Invitations have been extended to urologists attending LUGPA 2011.

A keynote presentation will be provided on the significance of DNA testing in the biopsy evaluation process, as well as an update and discussion on the know error® system's performance within large urology group practice settings.

"We Are Ready for a DNA Timeout"
John Pfeifer, MD, PhD, Vice Chairman for Clinical Affairs, Pathology and Immunology,
Washington University School of Medicine

"Know Error Best Practices"
Ann Anderson, MD, Director of Pathology, Integrated Medical Professionals

Know Error develops and markets the know error® system which utilizes bar coding, forensic principles and DNA matching to confirm that the biopsy samples being evaluated belong to the patient being diagnosed. Since the company's launch in 2009, hundreds of physicians in a variety of specialties, including urology, have incorporated the know error® system as a standard for their patient care.

To learn more about the know error® system for prostate biopsies, visit our website www.knowerror.com.

The know error® system for prostate biopsies will be showcased at the Annual Meeting of the Large Urology Group Practice Association (LUGPA). The meeting is being held November 3-5, 2011 at the Drake Hotel in Chicago. Click here to learn more about this meeting.

Know Error develops and markets the know error® system which utilizes bar coding, forensic principles and DNA matching to confirm that the biopsy samples being evaluated belong to the patient being diagnosed. Available for a diverse range of tissue types, including prostate, the know error® system brings new levels of patient safety and diagnostic accuracy to the biopsy evaluation process.

Since the company's launch in 2009, hundreds of physicians in a variety of specialties, including urology, have incorporated the know error® system as a standard for their patient care. To learn more about the know error® system for prostate biopsies, visit our website www.knowerror.com.

Know Error is proud to be a part of the 8th Annual Lee-Ann Riley Memorial Breast Symposium -- "Emerging Trends in Breast Cancer Management: From Diagnosis to Survivorship." The symposium is being hosted by the Norma F. Pfriem Breast Care Center at Bridgeport Hospital and takes place on October 26, 2011 in Shelton, CT. Click here for more information on this meeting.

The Norma F. Pfriem Breast Care Center is dedicated to providing a comprehensive network of services for complete breast health. Its multidisciplinary team of breast cancer specialists provides one-on-one care, with dignity, privacy, and warmth, in a serene, comfortable, thoroughly professional setting.

Know Error develops and markets the know error® system for breast biopsies which utilizes bar coding, forensic principles and DNA matching to confirm that the biopsy samples being evaluated belong to the patient being diagnosed. Available for a diverse range of tissue types, including breast, the know error® system brings new levels of patient safety and diagnostic accuracy to the biopsy evaluation process.

To learn more about the know error® system for breast biopsies, visit our website www.knowerror.com.

The know error® system for prostate biopsies is set to exhibit at the upcoming joint meeting of the New England and Mid-Atlantic Sections of the AUA. The meeting runs from November 3-6, 2011 at the Walt Disney World Swan Hotel in Orlando, FL. Click here for more information on this meeting.

Know Error develops and markets the know error® system which utilizes bar coding, forensic principles and DNA matching to confirm that the biopsy samples being evaluated belong to the patient being diagnosed. Available for a diverse range of tissue types, including prostate, the know error® system brings new levels of patient safety and diagnostic accuracy to the biopsy evaluation process.

Since the company's launch in 2009, hundreds of physicians in a variety of specialties, including urology, have incorporated the know error® system as a standard for their patient care. To learn more about the know error® system for prostate biopsies, visit our website www.knowerror.com.

The know error® system for prostate biopsies is set to exhibit at the North Central Section of the AUA's annual meeting which runs from October 18-22, 2011. This meeting will take place at The Westin Mission Hills in Rancho Mirage, CA. To find out more about this meeting, click here.

Know Error develops and markets the know error® system which utilizes bar coding, forensic principles and DNA matching to confirm that the biopsy samples being evaluated belong to the patient being diagnosed. Available for a diverse range of tissue types, including prostate, the know error® system brings new levels of patient safety and diagnostic accuracy to the biopsy evaluation process.

Since the company's launch in 2009, hundreds of physicians in a variety of specialties, including urology, have incorporated the know error® system as a standard for their patient care. To learn more about the know error® system for prostate biopsies, visit our website www.knowerror.com.

On October 1, 2011, the Victoria Herald Sun reported on a biopsy labeling mix-up that resulted in the unnecessary removal of an Australian woman's spleen as well as part of her pancreas. Fifty-six year old, Christine Korolew, was given the diagnosis of cancer in January 2010 after a pancreatic lesion was biopsied and revealed cancer.

As with most cases covered in this blog, the mix-up was revealed when routine post surgical tests showed no evidence of cancer. Korolew is pursuing legal action and her claim alleges that "a slide containing a biopsy specimen from another patient had been mislabeled with [her] name." The unnecessary removal of part of her pancreas additionally caused her to develop diabetes which requires two injections of insulin every day. The suit also claims that her ability to continue working has been affected and her former employer confirmed that "she is unlikely to be gainfully employed again."

The article makes no mention of the patient with whom Ms. Korolew's slides were switched.

Launched in 2009, the know error® system was developed to prevent this type of mix-up from occurring. The system utilizes bar coding, forensic principles and DNA matching to confirm that the biopsy samples being evaluated belong to the patient being diagnosed. In this case, the mislabeling would have been detected prior to any treatment taking place. Ms. Korolew would not have undergone unnecessary surgery or developed diabetes and the other patient involved in the mix-up would not have experienced any delay in treatment.

Available for a diverse range of tissue types, the know error® system brings new levels of patient safety and diagnostic accuracy to the biopsy evaluation process. To learn more about the know error® system, visit our website www.knowerror.com.

The know error® system for prostate biopsies is exhibiting at the Connecticut Society of Urology's Annual Scientific Education Program. The event takes place on October 6, 2011 from 8:00am - 5:00pm at The Aqua Turf Club in Plantsville, CT. Click here for more information on this meeting.

Launched in 2009, the know error® system for prostate biopsies brings a new standard of patient safety and diagnostic accuracy to the biopsy evaluation process. By establishing specimen provenance as part of the biopsy evaluation process, the know error® system arms physicians with critical information to recommend the appropriate path for patient treatment. Hundreds of physicians in a variety of specialties, including urology, have incorporated the know error® system as a standard for their patient care.

To learn more about the know error® system for prostate biopsies, visit our website www.knowerror.com.

Starting tomorrow, the know error® system for prostate biopsies will be exhibiting at the Florida Urological Society's Annual Meeting. The meeting runs from September 1-4, 2011 and is being held at the Hyatt Regency Coconut Point in Bonita Springs, Florida. Come visit us at Booth #353.

Launched in 2009, the know error® system for prostate biopsies brings a new standard of patient safety and diagnostic accuracy to the biopsy evaluation process. Through our innovative use of forensic chain of custody principles and DNA testing, the know error® system confirms that the biopsy samples being evaluated belong to the patient being diagnosed. As a result, the system has identified DNA non-matches in more than 1% of the patient cases for whom testing has been performed.

To learn more about the know error® system for prostate biopsies, visit our website www.knowerror.com.

The know error® system for breast biopsies will be participating at the Society of Breast Imaging's (SBI) next course -- "Practical Breast MRI: Case Based Review." The course takes place September 17-18, 2011 at the Loews Santa Monica Beach Hotel in Santa Monica, CA. Look for our tabletop display in the registration area.

The know error® system for breast biopsies brings a new standard of patient safety and diagnostic accuracy to the biopsy evaluation process. By establishing specimen provenance as part of the biopsy evaluation process, the know error® system arms physicians with critical information to recommend the appropriate path for patient treatment. Since its launch in the spring of 2010, the system has identified DNA non-matches in more than 1% of the patient cases for whom testing has been performed.

To learn more about the know error® system for breast biopsies, visit our website www.knowerror.com.

The know error® system for prostate biopsies will be showcased at the Annual Meeting of the Western Section of the American Urological Association (AUA). The meeting is being held August 21-25, 2011 at the Westin Bayshore in Vancouver, BC. Look for us at Booth #57.

The know error® system for prostate biopsies brings a new standard of patient safety and diagnostic accuracy to the biopsy evaluation process. Through our innovative use of forensic chain of custody principles and DNA testing, the know error® system confirms that the biopsy samples being evaluated belong to the patient being diagnosed. Since its launch in 2009, the system has identified DNA non-matches in more than 1% of the patient cases for whom testing has been performed.

To learn more about the know error® system for prostate biopsies, visit our website www.knowerror.com.

The know error® system for prostate biopsies will be exhibiting this week at the Annual Meeting of the AUA. The meeting kicks off this Saturday, May 14 and lasts through Thursday May 19. The meeting is being held at Walter E. Washington Convention Center in Washington, DC. Look for us at booth #3150. For more information on this meeting, click here.

The know error® system, introduced in the spring of 2009, provides an effective way to establish specimen provenance. 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.

For more information on the know error® system for prostate biopsies, visit our website www.knowerror.com. 

A Boston Globe article, "Mistakes That Matter," discussed the case of two men who were adversely affected by mix ups in the biopsy evaluation process. This post covers the case of the second man in the article (read previous post) who experienced an 8 month delay in his cancer treatment due to a lab mix up. The delay resulted in his cancer spreading to a lymph node and could mean radiation treatment (that would not have been necessary) in addition to the removal of his prostate.

In the article, the patient commented, "Labs are a pretty important part of the whole medical thing, and to have them screw up a fairly simple thing like that makes me wary." From a patient's perspective, it may seem like this would be a simple process, but medical experts have shown that evaluating biopsies is far from simple (read more).

In the first case from the article, the mix-up occurred when the slides were being reviewed by the pathologist (after leaving the pathology lab). In the second case, the mix up occurred at the lab when the lab technician placed the patient's tissue samples on blank slides labeled for another patient. By the time the pathologist reviewed the slides, the mix up had already occurred. Further, the mix up happened even though there were numbering and color coding quality control processes in place. This reemphasizes the complexity of the biopsy evaluation process and the need for a system that goes beyond procedural improvements.

Launched in the spring of 2009, the know error® system for prostate biopsies brings new levels of safety and accuracy to the biopsy evaluation process. The system incorporates bar code technology as well as DNA Specimen Provenance Assignment (DSPA). By performing DNA testing of biopsy tissue samples PRIOR to any treatment taking place, the know error® system virtually eliminates any adverse patient outcomes due to Specimen Provenance Complications (see previous post for more on SPCs). Through these combined features, the system allows both patient and physician to proceed confidently with treatment options based on the patient's lab results.

For more information about the know error® system for prostate biopsies, please visit our website www.knowerror.com

A Boston Globe article, "Mistakes That Matter," reported on two lawsuits filed as a result of medical mistakes that led to one unnecessary prostate surgery and another delay in prostate cancer treatment. While the cases in this article are similar, they are not related and consequently, will be discussed in separate posts.

The first case involved a man who was mistakenly told he had prostate cancer after the pathologist who reviewed his slides attributed his results to those of another patient who did have cancer. This led to the unnecessary removal of his prostate, incontinence, and erectile dysfunction.

The hospital responsible for the mix-up has stated, "...it will take several simple steps, including requiring pathologists to initial biopsy reports to show they took a "time out'' to make sure the reports match the slides." While many of the cases documented in this blog discuss the mix-up of biopsy tissue samples or tissue contamination, this case is different in that the tissue samples were evaluated correctly. The complication didn't occur until the very end of the biopsy evaluation process when the pathologist applied one patient's results to another patient.

This misapplication by the pathologist is just one type of Specimen Provenance Complication (SPC) that can occur as a result of the complex biopsy evaluation process. SPCs may arise due to instances of specimen transposition, foreign cell contamination, and patient misidentification (as in this case) that occur in clinical or anatomical pathology.

In the article, Dr. Gordon Schiff, associate professor at Harvard Medical School states, "One way to prevent mix-ups with biopsy tissue, for example, is to use bar codes to match specimens and slides." While methods such as bar coding and mandatory "time outs" may be effective at reducing SPCs, they may not be enough to prevent adverse patient outcomes such as those discussed here.

Launched in the spring of 2009, the know error® system for prostate biopsies brings new levels of safety and accuracy to the biopsy evaluation process. The system incorporates bar code technology as well as DNA Specimen Provenance Assignment (DSPA). By performing DNA testing of biopsy tissue samples PRIOR to any treatment taking place, the know error® system virtually eliminates any adverse patient outcomes due to SPC.

For more information about the know error® system for prostate biopsies, please visit our website www.knowerror.com.

The know error® system for prostate biopsies is being showcased at the Annual Meeting of the American Urological Association (AUA). The meeting takes place May 14-19, 2011 Walter E. Washington Convention Center in Washington, DC. Look for us at booth #3150. For more information on this meeting, click here.

The know error® system, introduced in the spring of 2009 by Diagnostic ID, LLC, provides an effective way to establish specimen provenance. 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 dramatically reduces the incidence of Specimen Provenance Complications (SPC) which may arise due to instances of specimen transposition, foreign cell contamination, and patient misidentification that occur in clinical or anatomical pathology. By performing DNA testing of biopsy tissue samples PRIOR to any treatment taking place, the know error® system virtually eliminates any adverse patient outcomes due to SPC.

For more information about the know error® system for prostate biopsies, please visit our website www.knowerror.com.

In July 2010, Fox 4 News in Dallas reported on a medical mix-up that nearly led to an unnecessary double mastectomy for one Texas woman. Romona Champion had a routine mammogram in February of 2009 that showed a suspicious mass. She had a biopsy done three weeks later and soon found out the biopsy revealed she had breast cancer. 

She delayed her scheduled surgery in order to take a long-planned family vacation. Two days before the trip, she found out there was a mistake in her diagnosis and that she was cancer-free. The pathology lab had mislabeled her specimen container with the name of another woman who did have breast cancer. The mix-up was only discovered because the other woman's doctor was concerned that his patient, who had all the signs of breast cancer, was reported to be cancer-free.  

While the outcome could have been far worse, both women were still negatively affected by Specimen Provenance Complications (SPC). SPCs are a by-product of the complicated biopsy evaluation process and may arise due to instances of specimen transposition, foreign cell contamination, and patient misidentification that occur in clinical or anatomical pathology. The first woman (Romona Champion) had to deal with the belief that she had breast cancer and the second experienced a delay in treatment.

Launched in the summer of 2010, the know error® system for breast biopsies brings new levels of safety and accuracy to the biopsy evaluation process. Through the use of DNA Specimen Provenance Assignment (DSPA) and bar code technology, this innovative system dramatically reduces the incidence of Specimen Provenance Complications (SPC) enhancing patient safety and diagnostic accuracy. By performing DNA testing of biopsy tissue samples PRIOR to any treatment taking place, the know error® system virtually eliminates any adverse patient outcomes due to SPC.

For more information about the know error® system for breast biopsies, please visit our website www.knowerror.com.

The know error® system for breast biopsies is being showcased at the Annual Meeting of the American Society of Breast Surgeons. The meeting will be held April 27- May 1, 2011 at the Marriott Wardman Park in Washington, DC. Look for us at Booth #429. For more information on this meeting, click here.

The know error® system for breast biopsies, introduced in the summer of 2010 by Diagnostic ID, LLC, provides an effective way to establish specimen provenance. 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 dramatically reduces the incidence of Specimen Provenance Complications (SPC) which may arise due to instances of specimen transposition, foreign cell contamination, and patient misidentification that occur in clinical or anatomical pathology. By performing DNA testing of biopsy tissue samples PRIOR to any treatment taking place, the know error® system virtually eliminates any adverse patient outcomes due to SPC.

For more information about the know error® system for breast biopsies, please visit our website www.knowerror.com.

The know error® system for prostate biopsies is being showcased at the 75th Annual Meeting of the Southeastern Section of the American Urological Association (AUA). The meeting is being held March 17-20, 2011 at the Marriott New Orleans. For more information on this meeting, click here.

The know error® system, introduced in the spring of 2009 by Diagnostic ID, LLC, provides an effective way to establish specimen provenance. 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 dramatically reduces the incidence of Specimen Provenance Complications (SPC) which may arise due to instances of specimen transposition, foreign cell contamination, and patient misidentification that occur in clinical or anatomical pathology. By performing DNA testing of biopsy tissue samples PRIOR to any treatment taking place, the know error® system virtually eliminates any adverse patient outcomes due to SPC.

For more information about the know error® system for prostate biopsies, please visit our website www.knowerror.com.

The know error® system for breast biopsies is being showcased at the National Consortium of Breast Centers' National Interdisciplinary Breast Center Conference. The meeting is being held March 12-13, 2011 at the Planet Hollywood Resort & Casino in Las Vegas. Look for us at Booth #23. For more information on this meeting, visit www.breastcare.org.

The know error® system for breast biopsies, introduced in the summer of 2010 by Diagnostic ID, LLC, provides an effective way to establish specimen provenance. 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 dramatically reduces the incidence of Specimen Provenance Complications (SPC) which may arise due to instances of specimen transposition, foreign cell contamination, and patient misidentification that occur in clinical or anatomical pathology. By performing DNA testing of biopsy tissue samples PRIOR to any treatment taking place, the know error® system virtually eliminates any adverse patient outcomes due to SPC.

For more information about the know error® system for breast biopsies, please visit our website www.knowerror.com.

On July 20, 2010, a story in The Vancouver Sun revealed a case where an accidental biopsy mix up resulted in an unnecessary lumpectomy for one woman and a 10 week delay in treatment for another.

As with similar cases documented in this blog, the mix up was discovered by a pathologist performing routine post-surgical tests that revealed no cancer in the patient's tissue samples.  The report states, "...DNA tests confirmed on July 16 that the woman's initial biopsy...was accidentally switched with a similar biopsy from another woman."  This type of mix up is just one of many types of Specimen Provenance Complications (SPC) that can lead to diagnostic mistakes.  Other examples of SPC are specimen transposition and foreign cell contamination. 

Launched in the summer of 2010, the know error® system for breast biopsies brings new levels of safety and accuracy to the biopsy evaluation process.  Through the use of DNA Specimen Provenance Assignment (DSPA) and bar code technology, this innovative system dramatically reduces the incidence of SPC so that diagnostic mistakes are minimized. 

While the DNA tests in this case confirmed the mix up, this was unfortunately AFTER the unnecessary surgery and delay in treatment.  The know error® system performs DSPA of biopsy tissue samples PRIOR to any treatment taking place and virtually eliminates diagnostic mistakes due to SPC.  This allows both patient and physician to proceed confidently with treatment options based on the patient's biopsy results.

For more information about the know error® system for breast biopsies, please visit our website www.knowerror.com.

On February 23, 2010, The College of American Pathologists posted an article on its web site titled, "When a Rose Is Not a Rose."  The article discusses the problem of mislabeled specimens and the procedural improvements that can be made to prevent labeling errors.

The article explains that "...reporting a wrong result can have potentially devastating effects on the patient. This can be doubly true if there is a patient identification mix-up: one patient could receive the wrong medical or surgical treatment while another doesn't get the treatment he or she needs. Either situation can result in severe, irreversible consequences."  As a remedy to the various types of labeling errors it covers, the article offers several procedural improvements such as reviewing definitions, guidelines and the protocol for what to do when an error is detected.