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 for prostate biopsies is exhibiting at the annual James C. Kimbrough Urological Seminar of the Society of Government Service Urologists being held January 15 - 20, 2012 at the Charleston Marriott in Charleston, South Carolina. The host institution for the meeting is the Naval Medical Center Portsmouth. 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.
]]>This is different than the chain of events leading to a misdiagnosis that have occurred in most cases covered in this blog. Typically, a lab mix up occurs which results in a false diagnosis, ultimately leading to unnecessary surgery and/or treatment for cancer. It is not until after the surgery that the routine post surgical tests of the biopsied tissue reveal there was no cancer in the first place. In this case, the testing of the post surgical biopsy tissue (from an unrelated surgery) was where the mistake and resulting misdiagnosis occurred.
Regardless of where the error occurred in the complex biopsy evaluation process, it is possible to avoid adverse outcomes such as these. 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. In this case, DNA testing conducted prior to treatment would have revealed two tissue types and that the one with cancer did not match this patient's DNA.
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 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.
]]>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.
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.
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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.]]>
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.
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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.
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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
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, 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.
]]>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, 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, 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.
]]>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.
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