Pathology Inc. Consensus Conference
October 9, 2007

Topic of the Day

Cancer-free woman Underwent Double Mastectomy because of Lab Mix-up

In a tragic turn of events, an apparent laboratory mixup resulted in a cancer diagnosis for a woman who was cancer free. She ended up receiving a double mastectomy. It was not until after the surgery and before her chemotherapy that she was informed that there was mistake; she did not have cancer.

The article explains with the cryptic statement, "The state report said 'the most likely source of the error' was the technician engaging in a practice called “batching,” which involves handling more than one specimen at a time."

I have no idea what that statement actually means but I think all of us can certainly understand or conjure scenarios how such a tragic turn of events could occur in any laboratory, including our own.

This case and others like it have spurred me to think about procedure and precautions we can immediately adopt to minimize or eliminate this type of error from ever happening. While systemic procedural quality control and management issues need to be in place and documented within every laboratory, I believe there are even simpler precautions that one can undertake.

One task I routinely do whenever I diagnose a malignancy is to do a double-check and compare the information on the printed slide label with the case number written on the frosted label, usually covered by the slide label. At Pathology Inc. we have slightly displaced the printed slide label toward the tissue section of the slide. In this fashion, one can immediately compare the written case number with the printed case number on the label at one glance. If your laboratory does not do this, one can utilize a mirror and hold the back of the glass slide to the mirror, creating a correctly imaged view of the written case number.

At Pathology Inc, all malignancies (excluding skin squamous cell carcinomas and basal cell carcinomas) are reviewed by a second pathologist. This second pathologist can also be integrated within this double check, perhaps even documenting the slide label double check on a quality control sheet. These tasks are simple, would take no extra time, and could potentially prevent a tragic event like the one depicted in the news story.

I welcome your email comments.

Journal Articles Reviewed

DermpathMD-Current Case Study

Issues in Dermatopathology