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 Errors (SPE) that can lead to diagnostic mistakes.  Other examples of SPE are specimen transposition and foreign cell contamination. 

Launched in the spring of 2009, the know error® system brings new levels of safety and accuracy to the biopsy evaluation process.  Through the use of forensic DNA testing and bar code technology, this innovative system dramatically reduces the incidence of SPE -- and identifies otherwise undetected SPE -- 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 forensic DNA testing of biopsy tissue samples PRIOR to any treatment taking place and virtually eliminates diagnostic mistakes due to SPE.  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, please visit our web site www.knowerror.com.

In December 2009, a report out of Obrezje, Slovenia revealed a lab switching error that resulted in the unnecessary complete stomach removal of a healthy woman, 50-year old Anica Kavecic.  Kavecic had no history of gastric problems, but when a biopsy showed a pervasive cancer in her stomach, she was urged to have an immediate and total gastrectomy. 

The diagnosis stunned both Kavecic and her family physician but the biggest shock came after the surgery when routine post-surgical tests revealed her stomach was cancer-free.  Her biopsy tissue samples had been switched with those of another patient, who in fact did have stomach cancer, resulting in the removal of her perfectly healthy stomach.   

Recent posts discussing the cases of Darrie Eason, Scott Aprile and "Kim," a woman from Korea, revealed three similar yet different situations.  Each involved some form of patient misidentification error that resulted in a cancer-free patient undergoing unnecessary breast removal surgery.  Media coverage of these types of cases tends to focus on the patient who received some form of unnecessary treatment.  While tragic for these patients, the reports seem to overlook a second and possibly more tragic victim - the patient WITH cancer who received delayed treatment or worse, no treatment at all.

The January 2009 feature story of CAP TODAY, "Using Lean to End Labeling Errors," discussed the implementation of a bar-coding initiative at the surgical pathology lab at Henry Ford Health System.  The program was considered a success reducing labeling problems by 85%, according to Dr. Mark Tuthill, director of pathology informatics. 

The new "Lean" protocol involved bar-coding all patient-related materials - requisition form, tissue cassettes, specimen containers, and slides - all at the same time.  Upon entering a patient into the system, the accessioner would print all of the bar codes for a particular patient.  There were technological challenges with the bar-coding since linear bar codes couldn't be used.  Tuthill partnered with General Data out of Cincinnati which had created a new cassette labeling system which could work in conjunction with the existing lab information system.