Breasts removed unnecessarily after lab mix-up
Four women who were told they had cancer and needed to have their breasts removed went ahead with the operation only to find out afterwards that there had been a mix-up with specimens.
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They never had cancer and never needed the operation but they still had to go through the ordeal of being told they were gravely ill, and endure surgery.
The mix-up was highlighted in the Health Ministry's Report of the National Panel to Review Breast Biopsy Errors, which was released yesterday.
On the cover of the report, a patient sums up her experience by saying she is not an "outcome" but rather a "patient with feelings and emotions".
A clinician affected by the errors said while medical staff do so many good things and generally have very high standards "just one mistake can be devastating".
Nothing could be truer for the women at the centre of these mistakes.
The errors occurred in both hospital and community laboratories when specimen samples - one from a patient with cancer and one from a patient without - were placed side by side and the identity of the samples were mixed up.
The cases ranged from a 49-year-old woman who was seen through the breast screening programme who was found to have a benign mass lesion, to a woman who had a wide local excision 10 years prior and was found to have cancer in a follow-up assessment.
A panel of experts convened by the ministry found that the serious errors resulted in the patients undergoing unnecessary surgery.
In addition to the four mastectomies, another woman had surgery to her mouth, which involved having biopsy tissue removed as part of a partial maxillectomy in May last year.
She was told she had squamous cell carcinoma, a type of skin cancer, but when the sample was inspected post-operation, it was found to be non-cancerous.
The panel said that four of the errors resulted from specimens being associated with the wrong person and one resulted from a misinterpretation.
It made a number of recommendations, including improved reporting of serious events, improved collaboration between laboratories and a more consistent process for supporting patients affected by serious errors.
All of the cases have either been investigated or are currently being investigated.
The panel was satisfied that the other women who did have cancer, but were told they didn't, have had "appropriate investigation and early management" of their breast cancer.
The panel said it considered that overall quality processes in New Zealand laboratories were of a high standard.
It said that international evidence showed that the nature of processing anatomical pathology specimens was vulnerable to errors of this kind.
The ministry's chief medical officer Dr Don Mackie said he would be writing to all of the laboratories involved in November asking them to explain how they have improved their processes in response to these errors.
The women involved not only suffered physically and emotionally but also financially and they were all seeking compensation.
In one case, none of the scans on the woman's breasts showed any signs for concern, but when the biopsy results did "they went ahead with it anyway".
Prior to surgery, two of the women questioned aspects of their results that they didn't understand and were told it "was just terminology and how they write things", the report said.
Why were laboratory staff working on two samples at a time, one of the women queried.
"You don't interview two patients at a time; it's not a group thing."
They lost their jobs, their businesses, their confidence and became depressed, the report detailed.
Some of them have met up with the other women who their sample was mistaken for.
While some have received ACC compensation they say it's not enough and are considering seeking further compensation and legal advice.
They want someone to be held accountable for the mix up, however the panel did not investigate whether any disciplinary action had been taken against any medical or laboratory staff, a Ministry of Health spokesman said.
One woman waited three months for an apology from the laboratory involved after learning of the mistake. They all said that someone needed to be held accountable - the staff, the trainees and the trainers.
"There should be consequences," one said.
Their cases have highlighted that there are no standardised processes across laboratories for identifying, managing and reporting critical incidents involving loss, transposition or misinterpretation of specimens, the report said.
- © Fairfax NZ News
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